Provider Demographics
NPI:1427928878
Name:ORTIZ, ELLYSA
Entity type:Individual
Prefix:
First Name:ELLYSA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 CREEKSIDE RIDGE DR STE 280
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3504
Mailing Address - Country:US
Mailing Address - Phone:661-444-4391
Mailing Address - Fax:
Practice Address - Street 1:5401 RIDGECREST CT
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93313-5289
Practice Address - Country:US
Practice Address - Phone:661-444-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-10
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician