Provider Demographics
NPI:1558840785
Name:ORTIZO, JOHANN DONGON (PSB)
Entity type:Individual
Prefix:
First Name:JOHANN
Middle Name:DONGON
Last Name:ORTIZO
Suffix:
Gender:M
Credentials:PSB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 WILSHIRE BLVD STE 520
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5727
Mailing Address - Country:US
Mailing Address - Phone:714-312-6043
Mailing Address - Fax:
Practice Address - Street 1:6363 WILSHIRE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5727
Practice Address - Country:US
Practice Address - Phone:310-987-7455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
CAPSB94028346103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker