Provider Demographics
NPI:1568989192
Name:PORTILLO, JOHANNA (BA)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1204
Mailing Address - Country:US
Mailing Address - Phone:818-242-9681
Mailing Address - Fax:
Practice Address - Street 1:920 E BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1204
Practice Address - Country:US
Practice Address - Phone:818-242-9681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner