Provider Demographics
NPI:1457822710
Name:CORTEZ, CECILIA
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:CORTEZ
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 1:16360 ROSCOE BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-1219
Mailing Address - Country:US
Mailing Address - Phone:818-901-4830
Mailing Address - Fax:818-901-8985
Practice Address - Street 1:11565 LAUREL CANYON BLVD STE 116
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4650
Practice Address - Country:US
Practice Address - Phone:818-361-5030
Practice Address - Fax:818-361-1764
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109107106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XMedicaid