Provider Demographics
NPI:1407582695
Name:RAMIREZ PORTILLO, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RAMIREZ PORTILLO
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 1:14535 SHERMAN CIR
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3087
Mailing Address - Country:US
Mailing Address - Phone:818-732-8142
Mailing Address - Fax:
Practice Address - Street 1:14535 SHERMAN CIR
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3087
Practice Address - Country:US
Practice Address - Phone:818-732-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA12982101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner