Provider Demographics
NPI:1609285063
Name:PORTILLA, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:PORTILLA
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 1:14314 E FOX LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7112
Mailing Address - Country:US
Mailing Address - Phone:701-212-6722
Mailing Address - Fax:
Practice Address - Street 1:188 COHASSET LN
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2206
Practice Address - Country:US
Practice Address - Phone:530-345-1306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist