Healthcare Provider Details

I. General information

NPI: 1629429790
Provider Name (Legal Business Name): PEARL ORTIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PEARL LICANO CATC

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 UNIVERSITY AVE APT D
BERKELEY CA
94702-1762
US

IV. Provider business mailing address

1089 BLUEBELL DR APT 901
LIVERMORE CA
94551-1388
US

V. Phone/Fax

Practice location:
  • Phone: 154-410-1294
  • Fax:
Mailing address:
  • Phone: 925-533-7637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: