Provider Demographics
NPI:1538303722
Name:PORTILLO, DARIA (MFT)
Entity Type:Individual
Prefix:
First Name:DARIA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:DARIA
Other - Middle Name:OLGA
Other - Last Name:PORTILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:1139 N BRAND BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3012
Mailing Address - Country:US
Mailing Address - Phone:415-318-6150
Mailing Address - Fax:
Practice Address - Street 1:1139 N BRAND BLVD STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3012
Practice Address - Country:US
Practice Address - Phone:415-318-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist