MEDICARE: DR. BERTA ELISA ORTIZ PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY 9877	CA

General Provider Information

NPI Number	:	1790864239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERTA ELISA ORTIZ PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 2975
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90231-2975
Country	:	US
Telephone Number	:	323-969-0951
Fax Number	:	323-874-2022

Provider Business Practice Location Address
First Line	:	4221 WILSHIRE BLVD
Second Line	:	SUITE 290 7-A
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3512
Country	:	US
Telephone Number	:	323-969-0951
Fax Number	:	323-874-2022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	07/08/2007

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