Provider Demographics
NPI:1548683832
Name:PORTILLO, ALICIA DAWN
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:DAWN
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:DAWN
Other - Last Name:SCISSONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6401 DIEGO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-7071
Mailing Address - Country:US
Mailing Address - Phone:702-569-8203
Mailing Address - Fax:
Practice Address - Street 1:6401 DIEGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-7071
Practice Address - Country:US
Practice Address - Phone:702-569-8203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker