Provider Demographics
NPI:1780253732
Name:ORTIZ, MELISSA MARIE (AMFT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 AVENIDA PICO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-5681
Mailing Address - Country:US
Mailing Address - Phone:949-680-0516
Mailing Address - Fax:
Practice Address - Street 1:189 AVENIDA LA CUESTA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3144
Practice Address - Country:US
Practice Address - Phone:949-680-0516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
117651106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist