Provider Demographics
NPI:1851671572
Name:PORTORREAL, LISSA-ANN (PT)
Entity Type:Individual
Prefix:
First Name:LISSA-ANN
Middle Name:
Last Name:PORTORREAL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-5941
Mailing Address - Country:US
Mailing Address - Phone:951-736-4700
Mailing Address - Fax:
Practice Address - Street 1:1350 E DEVONSHIRE AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-8629
Practice Address - Country:US
Practice Address - Phone:951-925-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15571225X00000X
CA41947225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist