Provider Demographics
NPI:1003393075
Name:PORTIS, AMBER LAQUITA
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LAQUITA
Last Name:PORTIS
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 1:1500 S HAVEN AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-2973
Mailing Address - Country:US
Mailing Address - Phone:909-749-5204
Mailing Address - Fax:909-217-3456
Practice Address - Street 1:1500 S HAVEN AVE STE 250
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2973
Practice Address - Country:US
Practice Address - Phone:909-749-5204
Practice Address - Fax:909-217-3456
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist