Provider Demographics
NPI:1447380225
Name:ORTEGA, JUAN CARLOS (LCSW)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16121 JAMAICA AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-6113
Mailing Address - Country:US
Mailing Address - Phone:187-896-2500
Mailing Address - Fax:
Practice Address - Street 1:9131 QUEENS BLVD
Practice Address - Street 2:SUITE 618
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5501
Practice Address - Country:US
Practice Address - Phone:718-275-0983
Practice Address - Fax:718-275-7973
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0773921041C0700X
NY069871104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY136167177OtherFIDELIS NUMBER