Provider Demographics
NPI:1699223313
Name:PORTILLO, KATHERINE (MED, LCDC, LPC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:MED, LCDC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 EVENING BAY LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-9082
Mailing Address - Country:US
Mailing Address - Phone:281-415-7941
Mailing Address - Fax:631-998-4645
Practice Address - Street 1:2555 S SHORE BLVD STE C
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2934
Practice Address - Country:US
Practice Address - Phone:281-415-7941
Practice Address - Fax:409-750-2039
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)