Healthcare Provider Details

I. General information

NPI: 1538022058
Provider Name (Legal Business Name): ELIAS ORTEGA LLPC,LLMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3133 LAKESHORE DR
SAINT JOSEPH MI
49085-2647
US

IV. Provider business mailing address

313 W MARS ST
BERRIEN SPRINGS MI
49103-1134
US

V. Phone/Fax

Practice location:
  • Phone: 269-588-3167
  • Fax:
Mailing address:
  • Phone: 269-338-5887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4151001208
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451024748
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: