Provider Demographics
NPI:1265768899
Name:PEDERSEN-ORTIZ, KYLIE OLIVIA (LCSW)
Entity type:Individual
Prefix:MS
First Name:KYLIE
Middle Name:OLIVIA
Last Name:PEDERSEN-ORTIZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:300 HILLMONT STREET
Practice Address - Street 2:BLDG. 340, STE. 302
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-652-6608
Practice Address - Fax:805-652-6136
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW74365104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker