Provider Demographics
NPI:1821499930
Name:PORTUONDO, MARTA
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:PORTUONDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16465 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3779
Mailing Address - Country:US
Mailing Address - Phone:305-335-4045
Mailing Address - Fax:305-267-6920
Practice Address - Street 1:2500 SW 75TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2895
Practice Address - Country:US
Practice Address - Phone:305-264-5252
Practice Address - Fax:305-267-6920
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLISW148281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program