=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992525240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEWPORT MENTAL HEALTH CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2024
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 QUAIL ST STE 210
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-670-1111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 OLIVE AVE STE 533
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92648-5142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-670-1111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PRISCILLA MONIQUE PORTILLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-670-1111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------