Healthcare Provider Details

I. General information

NPI: 1467625368
Provider Name (Legal Business Name): EDWYN W. ORTIZ-NANCE PSYD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 N. DEMAREE ST.
VISALIA CA
93291-7896
US

IV. Provider business mailing address

1041 N. DEMAREE ST.
VISALIA CA
93291-7896
US

V. Phone/Fax

Practice location:
  • Phone: 559-635-4252
  • Fax: 559-635-4281
Mailing address:
  • Phone: 559-635-4252
  • Fax: 559-635-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY18170
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY18170
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPSY18170
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY18170
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY60221926
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPY60221926
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS60221926
License Number StateWA
# 8
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPS60221926
License Number StateWA
# 9
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60221926
License Number StateWA
# 10
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPS60221926
License Number StateWA
# 11
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: