Provider Demographics
NPI:1487277794
Name:PORTILLO, OSCAR RAFAEL
Entity type:Individual
Prefix:
First Name:OSCAR
Middle Name:RAFAEL
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2060
Mailing Address - Country:US
Mailing Address - Phone:301-850-1148
Mailing Address - Fax:866-250-3233
Practice Address - Street 1:9500 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2060
Practice Address - Country:US
Practice Address - Phone:301-850-1148
Practice Address - Fax:866-250-3233
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-117994106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician