Healthcare Provider Details

I. General information

NPI: 1043997489
Provider Name (Legal Business Name): KENIA DENISE PORTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 HICKORY LOOP
LAS CRUCES NM
88005-6587
US

IV. Provider business mailing address

301 PERKINS DR STE B
LAS CRUCES NM
88005-3248
US

V. Phone/Fax

Practice location:
  • Phone: 575-652-3155
  • Fax: 505-441-2871
Mailing address:
  • Phone: 575-652-3155
  • Fax: 505-441-2871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-287552
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: