Provider Demographics
NPI:1669997169
Name:PORTILLA, YANEXIS
Entity type:Individual
Prefix:
First Name:YANEXIS
Middle Name:
Last Name:PORTILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5551 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34291-4708
Mailing Address - Country:US
Mailing Address - Phone:239-286-8242
Mailing Address - Fax:
Practice Address - Street 1:5551 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34291-4708
Practice Address - Country:US
Practice Address - Phone:239-286-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023133800Medicaid