Provider Demographics
NPI:1881110823
Name:PORTILLO, PAOLA M
Entity type:Individual
Prefix:
First Name:PAOLA
Middle Name:M
Last Name: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 1:3480 BUSKIRK AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3480 BUSKIRK DR
Practice Address - Street 2:ST 210
Practice Address - City:PLESANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523
Practice Address - Country:US
Practice Address - Phone:925-933-2627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health