Provider Demographics
NPI:1275940173
Name:PORTAL, BRIZEYDA D
Entity Type:Individual
Prefix:
First Name:BRIZEYDA
Middle Name:D
Last Name:PORTAL
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 1:13412 VANOWEN ST
Mailing Address - Street 2:16
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 HUGHES WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-1876
Practice Address - Country:US
Practice Address - Phone:310-221-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-13
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF89946106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist