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General NPI Number Information
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NPI Number | 1255882577
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Entity Type | Individual
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Provider Name | AMANDA RAQUEL PORTILLO MFTI
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Gender | Female
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Dates
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Enumeration Date | 10/21/2016
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 1234 EMPIRE ST SUITE 2300
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City | FAIRFIELD
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State | CA
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Zip | 94533-5711
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Country | US
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Telephone | 707-384-7303
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Fax | 707-247-4233
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Provider Business Mailing Address
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Address Line | 1234 EMPIRE ST SUITE 2300
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City | FAIRFIELD
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State | CA
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Zip | 94533-5711
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Country | US
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Telephone | 707-514-3764
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 95665
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License Number State | CA
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