1255882577 NPI number — AMANDA RAQUEL PORTILLO MFTI

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255882577 NPI number — AMANDA RAQUEL PORTILLO MFTI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTILLO
Provider First Name:
AMANDA
Provider Middle Name:
RAQUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MFTI
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255882577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 EMPIRE ST
Provider Second Line Business Mailing Address:
SUITE 2300
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94533-5711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-514-3764
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 EMPIRE ST
Provider Second Line Business Practice Location Address:
SUITE 2300
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94533-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-384-7303
Provider Business Practice Location Address Fax Number:
707-247-4233
Provider Enumeration Date:
10/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  95665 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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