1447423157 NPI number — MRS. CLYTE LYDIA PORTIS LCSW, LISW-CP

Table of content: MRS. CLYTE LYDIA PORTIS LCSW, LISW-CP (NPI 1447423157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447423157 NPI number — MRS. CLYTE LYDIA PORTIS LCSW, LISW-CP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTIS
Provider First Name:
CLYTE
Provider Middle Name:
LYDIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, LISW-CP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447423157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
254 41ST ST
Provider Second Line Business Mailing Address:
BLDG 40709
Provider Business Mailing Address City Name:
FORT GORDON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30905-5918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-787-1595
Provider Business Mailing Address Fax Number:
706-787-1099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
254 41ST ST
Provider Second Line Business Practice Location Address:
BLDG 40709
Provider Business Practice Location Address City Name:
FORT GORDON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30905-5918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-787-1595
Provider Business Practice Location Address Fax Number:
706-787-1099
Provider Enumeration Date:
04/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  CSW003792 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CSW003792 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041S0200X , with the licence number: CSW003792 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CSW003792 . This is a "GA SOCIAL WORK LICENSURE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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