Basic Information
| Provider Information | |||||||||
| NPI: | 1144782921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTILLO | ||||||||
| FirstName: | ALEXANDRIA | ||||||||
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| Credential: | MA, SLP-CCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 934 E COSTILLA ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809033771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056603457 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17250 JACKSON CREEK PKWY STE 220 | ||||||||
| Address2: | |||||||||
| City: | MONUMENT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801327300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194883348 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 14229709 | CO | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 14229709 | 01 | AMERICAN SPEECH AND HEARING ASSOCIATION | OTHER |