Healthcare Provider Details

I. General information

NPI: 1710347919
Provider Name (Legal Business Name): MARCELLA GERTRUDE PORTEWIG ACSW, LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 UNIVERSITY BLVD W THE PATHWAYS SCHOOLS
SILVER SPRING MD
20902-3302
US

IV. Provider business mailing address

6106 STARBURN PATH
COLUMBIA MD
21045-2570
US

V. Phone/Fax

Practice location:
  • Phone: 301-649-0778
  • Fax: 301-649-2598
Mailing address:
  • Phone: 410-312-4982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number04853
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberLC300543
License Number StateDC

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: