Provider Demographics
NPI:1790218014
Name:PORTOBANCO, MARIA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:PORTOBANCO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18713 NW 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2655
Mailing Address - Country:US
Mailing Address - Phone:786-394-0096
Mailing Address - Fax:
Practice Address - Street 1:18713 NW 46TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2655
Practice Address - Country:US
Practice Address - Phone:786-394-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14794224Z00000X
FLOT21851225X00000X
FLOT22240225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant