Healthcare Provider Details

I. General information

NPI: 1275651895
Provider Name (Legal Business Name): CHARLYN ORTAL ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4296
US

IV. Provider business mailing address

12181 PEACOCK CT APT 8
GARDEN GROVE CA
92841-3761
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2261
  • Fax: 626-577-2543
Mailing address:
  • Phone: 626-374-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: