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General NPI Number Information
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NPI Number | 1730635640
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Entity Type | Individual
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Provider Name | PORTIA RESNICK ATC, BCTMB
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Gender | Female
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Dates
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Enumeration Date | 08/31/2016
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Last Update Date | 08/21/2018
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Provider Practice Location Address
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Address Line | 5707 E 24TH PL
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City | TULSA
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State | OK
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Zip | 74114
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Country | US
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Telephone | 908-812-9320
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Fax |
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Provider Business Mailing Address
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Address Line | 5707 E 24TH PL
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City | TULSA
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State | OK
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Zip | 74114-3813
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 25MT00067100
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 18KT00365100
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 12938
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License Number State | HI
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Taxonomy #4
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 136
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License Number State | HI
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