Provider Demographics
NPI:1033885892
Name:PORTILLO, DANIELLE (BSW, SSW, MSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:BSW, SSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 MANOR WOOD DR N
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-8729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6051 FRANKFORT HWY STE 100
Practice Address - Street 2:
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616-9657
Practice Address - Country:US
Practice Address - Phone:231-882-4409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511017121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty