Healthcare Provider Details

I. General information

NPI: 1285261156
Provider Name (Legal Business Name): PORTIA PENDLETON, LCSW LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 MAIN ST STE 200
OLD SAYBROOK CT
06475-2357
US

IV. Provider business mailing address

12 ROGERS LAKE TRL
OLD LYME CT
06371-1223
US

V. Phone/Fax

Practice location:
  • Phone: 860-245-9598
  • Fax:
Mailing address:
  • Phone: 860-759-9162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: PORTIA PENDLETON
Title or Position: OWNER
Credential: LCSW
Phone: 860-759-9162