=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881472009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE BLAKE PORTO LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2023
-----------------------------------------------------
Last Update Date | 09/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 COMMUNITY LN
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12754-2851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-340-4105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 GLEN MANOR RD
-----------------------------------------------------
City | GLEN SPEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12737-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-331-2344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 121030
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------