Provider Demographics
NPI:1699449256
Name:FLORES PORTILLO, MIRIAM LIZETH
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:LIZETH
Last Name:FLORES 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 1:2314 CHATKA LN
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-2000
Mailing Address - Country:US
Mailing Address - Phone:909-264-5486
Mailing Address - Fax:
Practice Address - Street 1:2890 INLAND EMPIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4649
Practice Address - Country:US
Practice Address - Phone:909-233-7265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program