Healthcare Provider Details

I. General information

NPI: 1447761564
Provider Name (Legal Business Name): JOHANNA MAE PORTINGA LSWAIC, MSW, CDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 2ND AVE STE 208
SEATTLE WA
98101-1186
US

IV. Provider business mailing address

1920 2ND AVE STE 208
SEATTLE WA
98101-1102
US

V. Phone/Fax

Practice location:
  • Phone: 206-735-8738
  • Fax: 206-448-8495
Mailing address:
  • Phone: 206-495-5716
  • Fax: 206-448-8495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: