Basic Information
| Provider Information | |||||||||
| NPI: | 1720436660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTILLO | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | STEVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515305900 | ||||||||
| FaxNumber: | 9515305945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515305900 | ||||||||
| FaxNumber: | 9515305945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2016 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 109273 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.