Provider Demographics
NPI:1437663200
Name:PORTILLO, GIA DANIELLA
Entity Type:Individual
Prefix:MRS
First Name:GIA
Middle Name:DANIELLA
Last Name: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 1:7 VACQUERO LN
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-9318
Mailing Address - Country:US
Mailing Address - Phone:575-430-0246
Mailing Address - Fax:
Practice Address - Street 1:7 VACQUERO LN
Practice Address - Street 2:
Practice Address - City:TULAROSA
Practice Address - State:NM
Practice Address - Zip Code:88352-9318
Practice Address - Country:US
Practice Address - Phone:575-430-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician