Provider Demographics
NPI:1306529615
Name:PORTILLO, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
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 1:2651 IRVINE AVE STE 122
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-6645
Mailing Address - Country:US
Mailing Address - Phone:714-507-6884
Mailing Address - Fax:
Practice Address - Street 1:2651 IRVINE AVE STE 122
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-6645
Practice Address - Country:US
Practice Address - Phone:714-507-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127855106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist