Provider Demographics
NPI:1629169354
Name:PORTAL-QUEIROLO, LUIS A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:PORTAL-QUEIROLO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3990 WESTERLY PL STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2345
Mailing Address - Country:US
Mailing Address - Phone:714-488-9869
Mailing Address - Fax:949-955-1216
Practice Address - Street 1:3990 WESTERLY PL
Practice Address - Street 2:SUITE 160
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2310
Practice Address - Country:US
Practice Address - Phone:714-488-9869
Practice Address - Fax:949-955-1216
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19146103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical