Provider Demographics
NPI:1821157496
Name:PORTUGAL, ROXANNE DIONISIO (OTRL)
Entity Type:Individual
Prefix:MISS
First Name:ROXANNE
Middle Name:DIONISIO
Last Name:PORTUGAL
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 WESTVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648
Mailing Address - Country:US
Mailing Address - Phone:916-434-6886
Mailing Address - Fax:
Practice Address - Street 1:1550 3RD STREET
Practice Address - Street 2:LINCOLN MANOR CARE CENTER
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648
Practice Address - Country:US
Practice Address - Phone:916-645-6942
Practice Address - Fax:916-645-6942
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT3279225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist