Provider Demographics
NPI:1063077378
Name:PORTILLO, KAITLYNN M
Entity type:Individual
Prefix:
First Name:KAITLYNN
Middle Name:M
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 PACELLA PARK DR
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-1755
Mailing Address - Country:US
Mailing Address - Phone:910-333-0814
Mailing Address - Fax:
Practice Address - Street 1:200 DOCTORS DR STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6310
Practice Address - Country:US
Practice Address - Phone:910-333-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid