Basic Information
Provider Information
NPI: 1003004755
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ORTIZ
FirstName: LORI
MiddleName: M
NamePrefix: MS.
NameSuffix:  
Credential: M.A. LMHC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 4112
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871964112
CountryCode: US
TelephoneNumber: 5059779777
FaxNumber:  
Practice Location
Address1: 2403 SAN MATEO BLVD NE
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871104058
CountryCode: US
TelephoneNumber: 5058301871
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/09/2007
LastUpdateDate: 10/09/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000XT-0107161NMN Behavioral Health & Social Service ProvidersCounselor 
101YM0800XT-0107161NMY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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