Provider Demographics
NPI:1124161567
Name:REBOLLO PORTELA, JOSE A (MSW)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:A
Last Name:REBOLLO PORTELA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 CALLE GUSTAVO BECQUER
Mailing Address - Street 2:URB EL SENORIAL
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6946
Mailing Address - Country:US
Mailing Address - Phone:787-461-6773
Mailing Address - Fax:787-778-2801
Practice Address - Street 1:41 CALLE SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-778-2800
Practice Address - Fax:787-778-2801
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0055609Medicare ID - Type Unspecified
PRS58316Medicare UPIN