MEDICARE: MRS. MICHELLE DIANNE PORTMAN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0000003889	TN
2	104100000X	Social Worker	0000003889	TN

General Provider Information

NPI Number	:	1366585804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE DIANNE PORTMAN LCSW

Provider Business Mailing Address
First Line	:	111 CENTER PARK DR
Second Line	:	STE 1300
City	:	KNOXVILLE
State	:	TN
Zip	:	37922-2124
Country	:	US
Telephone Number	:	865-555-0593
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 CENTER PARK DR
Second Line	:	STE 1300
City	:	KNOXVILLE
State	:	TN
Zip	:	37922-2124
Country	:	US
Telephone Number	:	865-556-0593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/27/2016

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