Provider Demographics
NPI:1669945044
Name:PORTFOLIO, MARIE I (COTA)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:I
Last Name:PORTFOLIO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:MARIE
Other - Middle Name:I
Other - Last Name:PHILBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:336 S POWERLINE RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-8105
Mailing Address - Country:US
Mailing Address - Phone:954-572-5851
Mailing Address - Fax:
Practice Address - Street 1:336 S POWERLINE RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-8105
Practice Address - Country:US
Practice Address - Phone:954-572-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16082224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty