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General NPI Number Information
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NPI Number | 1609046788
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Entity Type | Organization
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Legal Business Name | PORTIS MARRIAGE AND CHILDREN COUNSELING CLINIC, LLC
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Dates
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Enumeration Date | 03/05/2008
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Last Update Date | 02/15/2011
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Provider Practice Location Address
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Address Line | 5801 WASHINGTON AVE STE 103
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City | RACINE
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State | WI
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Zip | 53406-4057
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Country | US
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Telephone | 262-884-9734
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Fax | 262-884-9735
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Provider Business Mailing Address
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Address Line | 5801 WASHINGTON AVE STE 110
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City | RACINE
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State | WI
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Zip | 53406-4057
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Country | US
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Telephone | 262-884-9734
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Fax | 262-884-9735
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Authorized Official
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Title or Position | CLINICAL DIRECTOR/THERAPIST
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Name | MRS. ALICE FAYE PORTIS-PATTERSON
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Credential | MSW, LPC
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Telephone | 262-884-9734
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 947-125
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License Number State | WI
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