Provider Demographics
NPI:1639624489
Name:PEREZ PORTILLO, ANDREA GUADALUPE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:GUADALUPE
Last Name:PEREZ PORTILLO
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 1:1375 SYCAMORE AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-5519
Mailing Address - Country:US
Mailing Address - Phone:510-253-5199
Mailing Address - Fax:
Practice Address - Street 1:1375 SYCAMORE AVE APT 211
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-5519
Practice Address - Country:US
Practice Address - Phone:510-253-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA74204101YM0800X, 104100000X, 390200000X
CA961341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program