Provider Demographics
NPI:1831357474
Name:DE LA PORTILLA, MANUEL (MH6485)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:DE LA PORTILLA
Suffix:
Gender:M
Credentials:MH6485
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3477 VIVIAN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-7886
Mailing Address - Country:US
Mailing Address - Phone:305-389-2374
Mailing Address - Fax:
Practice Address - Street 1:15660 SW 72ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1923
Practice Address - Country:US
Practice Address - Phone:786-697-1150
Practice Address - Fax:786-541-1526
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6485101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health