Provider Demographics
NPI:1376892190
Name:PORTILLO, BERTA ALICIA
Entity Type:Individual
Prefix:
First Name:BERTA
Middle Name:ALICIA
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BERTA
Other - Middle Name:ALICIA
Other - Last Name:PORTILLO ACOSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:313 HILLTOP ST
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4123
Mailing Address - Country:US
Mailing Address - Phone:505-433-8361
Mailing Address - Fax:
Practice Address - Street 1:313 HILLTOP
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:505-433-8361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7410225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist