Healthcare Provider Details

I. General information

NPI: 1174432090
Provider Name (Legal Business Name): VIVIAN PORTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 BLUE STREAM WAY APT 5101
INLET BEACH FL
32461-8621
US

IV. Provider business mailing address

1850 SW ALEDO LN APT 5211
PORT ST LUCIE FL
34953-4159
US

V. Phone/Fax

Practice location:
  • Phone: 305-879-2654
  • Fax:
Mailing address:
  • Phone: 305-879-2654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: