Healthcare Provider Details

I. General information

NPI: 1750594644
Provider Name (Legal Business Name): REGINA MARIE ORTEGA ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/16/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 MDG 280 DAVID L. GOLDFEIN STREET, BLDG 23,
HOLLOMAN AFB NM
88330
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 575-572-5676
  • Fax:
Mailing address:
  • Phone: 707-423-5174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: