Provider Demographics
NPI:1184161390
Name:ORTIZ, KATIE CAROLYN
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:CAROLYN
Last Name:ORTIZ
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 1:15305 RAYEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5117
Mailing Address - Country:US
Mailing Address - Phone:661-547-3501
Mailing Address - Fax:818-752-0783
Practice Address - Street 1:10526 DUBNOFF WAY
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3921
Practice Address - Country:US
Practice Address - Phone:818-755-4950
Practice Address - Fax:818-752-0783
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW90597101YM0800X
CALCSW1245631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#95-2633765Medicaid