Provider Demographics
NPI:1356142079
Name:PORTALES GOY, YISMELY
Entity type:Individual
Prefix:
First Name:YISMELY
Middle Name:
Last Name:PORTALES GOY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SW 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 SW 63RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-3848
Practice Address - Country:US
Practice Address - Phone:786-684-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-417558106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician