Provider Demographics
NPI:1366090912
Name:PORTIS, PAUL (RBT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PORTIS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5393 LUPINE AVE
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-1471
Mailing Address - Country:US
Mailing Address - Phone:442-241-4299
Mailing Address - Fax:
Practice Address - Street 1:5393 LUPINE AVE
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-1471
Practice Address - Country:US
Practice Address - Phone:442-241-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-97226106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician