Provider Demographics
NPI:1215786611
Name:PORTILLO, ERICK (RBT)
Entity type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 NW 72ND AVE STE 215B
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33166-2223
Mailing Address - Country:US
Mailing Address - Phone:786-865-4646
Mailing Address - Fax:
Practice Address - Street 1:7911 NW 72ND AVE STE 215B
Practice Address - Street 2:
Practice Address - City:MEDLEY
Practice Address - State:FL
Practice Address - Zip Code:33166-2223
Practice Address - Country:US
Practice Address - Phone:786-865-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-339385106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician