Provider Demographics
NPI:1073136412
Name:PORTELA, IDA ORLANDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:ORLANDA
Last Name:PORTELA
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 1:18260 MEDITERRANEAN BLVD APT 907
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6319 NW 173RD TER
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4487
Practice Address - Country:US
Practice Address - Phone:786-486-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20-117845106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician