Healthcare Provider Details

I. General information

NPI: 1053279760
Provider Name (Legal Business Name): MARIA GUADALUPE ORTIZ PONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2026
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1167 NW WALLULA AVE APT 140
GRESHAM OR
97030-3668
US

IV. Provider business mailing address

1167 NW WALLULA AVE APT 140
GRESHAM OR
97030-3668
US

V. Phone/Fax

Practice location:
  • Phone: 541-965-9490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: