Provider Demographics
NPI:1467012948
Name:ORTIZ, ILIANA MONICA
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:MONICA
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 1:1201 S VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2552
Mailing Address - Country:US
Mailing Address - Phone:747-257-0301
Mailing Address - Fax:
Practice Address - Street 1:1201 S VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-2552
Practice Address - Country:US
Practice Address - Phone:747-257-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5522316106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician