Provider Demographics
NPI:1538252143
Name:PORTILLO, RONI (MFTI)
Entity type:Individual
Prefix:MR
First Name:RONI
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MAREBLU STE 250
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3014
Mailing Address - Country:US
Mailing Address - Phone:949-643-6934
Mailing Address - Fax:
Practice Address - Street 1:5 MAREBLU STE 250
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3014
Practice Address - Country:US
Practice Address - Phone:949-643-6934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF86086106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist