Provider Demographics
NPI:1619561784
Name:ORTEGA, CLARISSA (BSW)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:ORTEGA
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 GRISWOLD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-2412
Mailing Address - Country:US
Mailing Address - Phone:818-723-0253
Mailing Address - Fax:
Practice Address - Street 1:8144 ESCONDIDO CANYON RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:CA
Practice Address - Zip Code:93510-1534
Practice Address - Country:US
Practice Address - Phone:661-678-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
CAASW1069021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACAMedicaid