Healthcare Provider Details

I. General information

NPI: 1790419638
Provider Name (Legal Business Name): JULIE PORTILLO LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 ABRECHT PL
FREDERICK MD
21701-4918
US

IV. Provider business mailing address

210 ABRECHT PL
FREDERICK MD
21701-4918
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-8263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number23299
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23299
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: