Provider Demographics
NPI:1255084745
Name:AUTHENTIC CONNECTIONS PSYCHOTHERAPY, INC.
Entity type:Organization
Organization Name:AUTHENTIC CONNECTIONS PSYCHOTHERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PERRINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:530-536-0663
Mailing Address - Street 1:11260 DONNER PASS RD. STE C1
Mailing Address - Street 2:PMB 635
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161
Mailing Address - Country:US
Mailing Address - Phone:530-536-0663
Mailing Address - Fax:
Practice Address - Street 1:10368 DONNER PASS RD
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0427
Practice Address - Country:US
Practice Address - Phone:530-536-0663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty