Provider Demographics
NPI:1629429790
Name:ORTIZ, PEARL
Entity Type:Individual
Prefix:
First Name:PEARL
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PEARL
Other - Middle Name:
Other - Last Name:LICANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAODC
Mailing Address - Street 1:1280 UNIVERSITY AVE APT D
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1762
Mailing Address - Country:US
Mailing Address - Phone:154-410-1294
Mailing Address - Fax:
Practice Address - Street 1:1280 UNIVERSITY AVE APT D
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1762
Practice Address - Country:US
Practice Address - Phone:154-410-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
00Other00