Provider Demographics
NPI:1902672603
Name:ORTIZ, DOMINIC SAVIO (SUDRC 16296)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:SAVIO
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:SUDRC 16296
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PETER BEHR DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5216
Mailing Address - Country:US
Mailing Address - Phone:415-473-4161
Mailing Address - Fax:
Practice Address - Street 1:13 PETER BEHR DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-5216
Practice Address - Country:US
Practice Address - Phone:415-473-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)