Basic Information
Provider Information | |||||||||
NPI: | 1285903096 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORTINEZ | ||||||||
FirstName: | JOHNNY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CORTINAS | ||||||||
OtherFirstName: | JOHNNY | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1500 N WESTWOOD BLVD | ||||||||
Address2: |   | ||||||||
City: | POPLAR BLUFF | ||||||||
State: | MO | ||||||||
PostalCode: | 639013318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5736864151 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 N WESTWOOD BLVD | ||||||||
Address2: |   | ||||||||
City: | POPLAR BLUFF | ||||||||
State: | MO | ||||||||
PostalCode: | 639013318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737784746 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2011 | ||||||||
LastUpdateDate: | 09/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 55920 | TX | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 55920 | TX | N |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.