Provider Demographics
NPI:1699449256
Name:FLORES PORTILLO, MIRIAM LIZETH
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:LIZETH
Last Name:FLORES 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 1:2314 CHATKA LN
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-2000
Mailing Address - Country:US
Mailing Address - Phone:909-264-5486
Mailing Address - Fax:
Practice Address - Street 1:2000 W BRIGGSMORE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker