Basic Information
| Provider Information | |||||||||
| NPI: | 1831133099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTELLO | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9315 GRAVELLY LAKE DR SW | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984991574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535815200 | ||||||||
| FaxNumber: | 2535815203 | ||||||||
| Practice Location | |||||||||
| Address1: | 17520 MERIDIAN E | ||||||||
| Address2: | SUITE F | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983756265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538647595 | ||||||||
| FaxNumber: | 2538640457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00014112 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7727PO | 01 | WA | REGENCE BLUESHIELD | OTHER | 8938246 | 01 | WA | L&I CRIME VICTIMS PROGRAM | OTHER | 142460 | 01 | WA | LABOR & INDUSTRIES | OTHER |