Basic Information
| Provider Information | |||||||||
| NPI: | 1710367149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTILLO | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | AURORA | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 E MOSHOLU PKWY S | ||||||||
| Address2: | 1E | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104581713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475858444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 HOYT ST | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112015809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188020666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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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 | 104100000X | 093310-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.