Provider Demographics
NPI:1730644832
Name:PORTILLLO, ROSSALYN NICOLE (SLP-ASSISTANT)
Entity type:Individual
Prefix:
First Name:ROSSALYN
Middle Name:NICOLE
Last Name:PORTILLLO
Suffix:
Gender:F
Credentials:SLP-ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12157 JOSE CISNEROS DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-0205
Mailing Address - Country:US
Mailing Address - Phone:915-252-6268
Mailing Address - Fax:
Practice Address - Street 1:12157 JOSE CISNEROS DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-0205
Practice Address - Country:US
Practice Address - Phone:915-252-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX409442355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty