Provider Demographics
NPI:1710714845
Name:PORTILLO, MARISSA ALLYSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ALLYSA
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 1:1300 17TH ST FL CLF4
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-4504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 6TH ST
Practice Address - Street 2:
Practice Address - City:TAFT
Practice Address - State:CA
Practice Address - Zip Code:93268-2306
Practice Address - Country:US
Practice Address - Phone:661-765-2127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool