Healthcare Provider Details

I. General information

NPI: 1780510339
Provider Name (Legal Business Name): KEVIN JOHN PORTAL PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CASE ST
NORWICH CT
06360-2271
US

IV. Provider business mailing address

101 BIDWELL ST
GLASTONBURY CT
06033-3004
US

V. Phone/Fax

Practice location:
  • Phone: 860-823-1399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12.018278
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: