Provider Demographics
NPI:1477945269
Name:PORTILLO, ELIZABETH (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28765 SINGLE OAK DR
Mailing Address - Street 2:SUITE # 125
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3661
Mailing Address - Country:US
Mailing Address - Phone:951-552-1126
Mailing Address - Fax:
Practice Address - Street 1:28765 SINGLE OAK DR
Practice Address - Street 2:SUITE # 125
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-3661
Practice Address - Country:US
Practice Address - Phone:951-552-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12447235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist