Provider Demographics
NPI:1477120152
Name:SEARA PORTALES, VIRNA LISIS (RBT)
Entity Type:Individual
Prefix:
First Name:VIRNA
Middle Name:LISIS
Last Name:SEARA PORTALES
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8909 WING TIP CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1049
Mailing Address - Country:US
Mailing Address - Phone:813-703-5230
Mailing Address - Fax:
Practice Address - Street 1:2700 N MACDILL AVE STE 206
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2273
Practice Address - Country:US
Practice Address - Phone:813-644-6538
Practice Address - Fax:813-200-3609
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-170832106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician