Provider Demographics
NPI:1013476688
Name:PORTILLO, DOMINIKA J (OTR)
Entity Type:Individual
Prefix:
First Name:DOMINIKA
Middle Name:J
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LISA ROBYN CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-7018
Mailing Address - Country:US
Mailing Address - Phone:732-766-8945
Mailing Address - Fax:
Practice Address - Street 1:2579 OCEAN AVE FL 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4552
Practice Address - Country:US
Practice Address - Phone:732-766-8945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
NJ46TR00863800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist