Provider Demographics
NPI:1689311953
Name:PORTILLO, LESLIE MARIE (MA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARIE
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 BRAND DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4503
Mailing Address - Country:US
Mailing Address - Phone:516-513-9313
Mailing Address - Fax:
Practice Address - Street 1:256 MAIN ST UNIT 7
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-7043
Practice Address - Country:US
Practice Address - Phone:631-759-8278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115259-01221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist