Healthcare Provider Details

I. General information

NPI: 1205339454
Provider Name (Legal Business Name): MANUEL A ORTEGA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 N GRANT ST STE A
SILVER CITY NM
88061
US

IV. Provider business mailing address

1311 N GRANT ST STE A
SILVER CITY NM
88061-5134
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-1447
  • Fax:
Mailing address:
  • Phone: 575-388-1447
  • Fax: 575-388-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11960
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: