Provider Demographics
NPI:1255903506
Name:PORTILLO, ALEXIS EMILY
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:EMILY
Last Name:PORTILLO
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 1:4520 POWELL POINT WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-4325
Mailing Address - Country:US
Mailing Address - Phone:702-350-8193
Mailing Address - Fax:
Practice Address - Street 1:1515 E TROPICANA AVE # 580
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6517
Practice Address - Country:US
Practice Address - Phone:702-898-5311
Practice Address - Fax:702-222-3275
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-1763104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker