Provider Demographics
NPI:1669922373
Name:ORNELAS, MAYRA SUSANA
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:SUSANA
Last Name:ORNELAS
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 1:19648 BRUCES PL
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-4800
Mailing Address - Country:US
Mailing Address - Phone:818-730-9230
Mailing Address - Fax:
Practice Address - Street 1:16360 ROSCOE BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1219
Practice Address - Country:US
Practice Address - Phone:818-901-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CALMFT123653106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist