Provider Demographics
NPI:1427662691
Name:PORTALATIN, YALISSA
Entity type:Individual
Prefix:
First Name:YALISSA
Middle Name:
Last Name:PORTALATIN
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 1:45 CONDUIT ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-6018
Mailing Address - Country:US
Mailing Address - Phone:787-431-4690
Mailing Address - Fax:
Practice Address - Street 1:53 LINDEN ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6904
Practice Address - Country:US
Practice Address - Phone:787-431-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty