Provider Demographics
NPI:1669018578
Name:PORTUONDO GINARTE, DEBORATH
Entity Type:Individual
Prefix:
First Name:DEBORATH
Middle Name:
Last Name:PORTUONDO GINARTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 NW 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4746
Mailing Address - Country:US
Mailing Address - Phone:305-988-4125
Mailing Address - Fax:
Practice Address - Street 1:5122 NW 79TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-4746
Practice Address - Country:US
Practice Address - Phone:305-988-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL772285Medicaid