Provider Demographics
NPI:1922300532
Name:ORTIZ, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
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 1:155 N OCCIDENTAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 N OCCIDENTAL BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4641
Practice Address - Country:US
Practice Address - Phone:213-381-2931
Practice Address - Fax:213-385-0884
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2019-12-11
Deactivation Date:2019-11-25
Deactivation Code:
Reactivation Date:2019-12-11
Provider Licenses
StateLicense IDTaxonomies
CAIMF 65145106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist