Healthcare Provider Details

I. General information

NPI: 1154545739
Provider Name (Legal Business Name): MARIA GUDADALUPE ORTEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 NATIONAL AVE
SAN DIEGO CA
92113-2113
US

IV. Provider business mailing address

2821 RAZOR WAY
RIVERSIDE CA
92509-2124
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2300
  • Fax:
Mailing address:
  • Phone: 951-864-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC49264
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: