=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538022058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIAS ORTEGA LLPC,LLMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3133 LAKESHORE DR
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-2647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-588-3167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 W MARS ST
-----------------------------------------------------
City | BERRIEN SPRINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49103-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-338-5887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 4151001208
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 6451024748
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------