Provider Demographics
NPI:1831934728
Name:PORTAL ESPINOSA, LETICIA MARIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:MARIA
Last Name:PORTAL ESPINOSA
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 1:1023 ENBROOK LOOP
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34114-9311
Mailing Address - Country:US
Mailing Address - Phone:239-645-6168
Mailing Address - Fax:
Practice Address - Street 1:1023 ENBROOK LOOP
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34114-9311
Practice Address - Country:US
Practice Address - Phone:239-645-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-356677106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician