Healthcare Provider Details

I. General information

NPI: 1609285063
Provider Name (Legal Business Name): KATHRYN PORTILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2014
Last Update Date: 08/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 COHASSET LN
CHICO CA
95926-2206
US

IV. Provider business mailing address

14314 E FOX LAKE RD
DETROIT LAKES MN
56501-7112
US

V. Phone/Fax

Practice location:
  • Phone: 530-345-1306
  • Fax:
Mailing address:
  • Phone: 701-212-6722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number39834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: