Provider Demographics
NPI:1457500589
Name:PORTILLO, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
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 1:206 HOSPITAL CIR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-3910
Mailing Address - Country:US
Mailing Address - Phone:714-895-1985
Mailing Address - Fax:
Practice Address - Street 1:206 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-3910
Practice Address - Country:US
Practice Address - Phone:714-895-1985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALVN 34924103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities