Provider Demographics
NPI:1306413026
Name:PORTUONDO, YANEISY
Entity Type:Individual
Prefix:
First Name:YANEISY
Middle Name:
Last Name:PORTUONDO
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 1:7130 W 11TH CT APT 11
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4649
Mailing Address - Country:US
Mailing Address - Phone:786-768-7394
Mailing Address - Fax:
Practice Address - Street 1:7130 W 11TH CT APT 11
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4649
Practice Address - Country:US
Practice Address - Phone:786-768-7394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-166061106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician