Basic Information
| Provider Information | |||||||||
| NPI: | 1013384387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ORTIZ | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 W 25TH AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944032208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502862090 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 126 W 25TH AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944032208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502862090 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2015 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 78966 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.