Healthcare Provider Details

I. General information

NPI: 1528669181
Provider Name (Legal Business Name): MARISOL ORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 GRAND AVE
NEW HAVEN CT
06513-3733
US

IV. Provider business mailing address

374 GRAND AVE
NEW HAVEN CT
06513-3733
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax: 203-777-8506
Mailing address:
  • Phone: 203-777-7411
  • Fax: 203-777-8506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9312
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: