Provider Demographics
NPI:1215466529
Name:ORTIZ, KELLY ALYNE (CADC-II)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ALYNE
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 E COOLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-6324
Mailing Address - Country:US
Mailing Address - Phone:909-485-8986
Mailing Address - Fax:
Practice Address - Street 1:2275 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6324
Practice Address - Country:US
Practice Address - Phone:909-370-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X101YM0800X
CAAII050770218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health