Healthcare Provider Details

I. General information

NPI: 1154246882
Provider Name (Legal Business Name): KEVIN PORTELLES ALFONSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 SW 204TH ST
CUTLER BAY FL
33189-2649
US

IV. Provider business mailing address

8100 SW 204TH ST
CUTLER BAY FL
33189-2649
US

V. Phone/Fax

Practice location:
  • Phone: 786-339-0594
  • Fax:
Mailing address:
  • Phone: 786-339-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2833699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: