Provider Demographics
NPI:1679845226
Name:PORTILLO-VIA, CRISTINA A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CRISTINA
Middle Name:A
Last Name:PORTILLO-VIA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91224-0003
Mailing Address - Country:US
Mailing Address - Phone:214-734-6664
Mailing Address - Fax:
Practice Address - Street 1:3049 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3659
Practice Address - Country:US
Practice Address - Phone:214-734-6664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-28
Last Update Date:2012-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX367481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical