Provider Demographics
NPI:1144782921
Name:PORTILLO, ALEXANDRIA (MA, SLP-CCC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:MA, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MANITOBA DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3322
Mailing Address - Country:US
Mailing Address - Phone:505-660-3457
Mailing Address - Fax:
Practice Address - Street 1:17230 JACKSON CREEK PKWY STE 220
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7304
Practice Address - Country:US
Practice Address - Phone:719-488-3348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14229709235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14229709OtherAMERICAN SPEECH AND HEARING ASSOCIATION