Healthcare Provider Details

I. General information

NPI: 1821655895
Provider Name (Legal Business Name): PORTIALYN BUZZANGA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16250 HOMECOMING DR UNIT 1306
CHINO CA
91708-8824
US

IV. Provider business mailing address

16250 HOMECOMING DR UNIT 1306
CHINO CA
91708-8824
US

V. Phone/Fax

Practice location:
  • Phone: 618-670-6219
  • Fax:
Mailing address:
  • Phone: 618-670-6219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number59616
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: