Provider Demographics
NPI:1245945468
Name:PORTALATIN LUIGGI, NESTOR XAVIER (PSYD)
Entity type:Individual
Prefix:
First Name:NESTOR
Middle Name:XAVIER
Last Name:PORTALATIN LUIGGI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB SAN ANTONIO
Mailing Address - Street 2:2049 CALLE DRAMA
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728
Mailing Address - Country:US
Mailing Address - Phone:787-600-4789
Mailing Address - Fax:
Practice Address - Street 1:URB SAN ANTONIO
Practice Address - Street 2:2049 CALLE DRAMA
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728
Practice Address - Country:US
Practice Address - Phone:787-600-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical