=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679190458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIELA ORTIZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2020
-----------------------------------------------------
Last Update Date | 06/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4645 CARTHAGE CIR S
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-7245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-340-1391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4645 CARTHAGE CIR S
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-7245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-340-1391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | 20122869
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------