Healthcare Provider Details

I. General information

NPI: 1487940755
Provider Name (Legal Business Name): ROGER ANTONIO PORTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N 19TH ST
MONTEBELLO CA
90640-3942
US

IV. Provider business mailing address

11741 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3681
US

V. Phone/Fax

Practice location:
  • Phone: 323-788-6298
  • Fax:
Mailing address:
  • Phone: 562-949-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW87707
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: