Provider Demographics
NPI:1588237226
Name:PORTILLO, GLORIA (LCDC)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E MAIN DR STE 600
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79901-1385
Mailing Address - Country:US
Mailing Address - Phone:915-887-3419
Mailing Address - Fax:
Practice Address - Street 1:8500 BOEING DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1224
Practice Address - Country:US
Practice Address - Phone:915-887-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16548101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty