Provider Demographics
NPI:1578398624
Name:ORTIZ COSME, KIRSTY JOAN
Entity type:Individual
Prefix:
First Name:KIRSTY
Middle Name:JOAN
Last Name:ORTIZ COSME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11461 SW 192ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8102
Mailing Address - Country:US
Mailing Address - Phone:305-801-7956
Mailing Address - Fax:
Practice Address - Street 1:14221 SW 120TH ST STE 214
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4224
Practice Address - Country:US
Practice Address - Phone:786-452-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1089976106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician