Provider Demographics
NPI:1598323818
Name:ORTIZ, DESTINEY M
Entity Type:Individual
Prefix:
First Name:DESTINEY
Middle Name:M
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 1:9010 EAST BURKE STREET UNIT 45
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660
Mailing Address - Country:US
Mailing Address - Phone:323-534-7115
Mailing Address - Fax:
Practice Address - Street 1:1212 N SAN DIMAS CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1223
Practice Address - Country:US
Practice Address - Phone:626-345-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-01
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-22-60620103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician