Provider Demographics
NPI:1104374230
Name:PENDLETON, PORTIA (LMSW)
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:PORTIA
Other - Middle Name:
Other - Last Name:KIMBIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 HEMPSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6204
Mailing Address - Country:US
Mailing Address - Phone:860-443-2896
Mailing Address - Fax:860-442-5909
Practice Address - Street 1:190 WESTBROOK RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1518
Practice Address - Country:US
Practice Address - Phone:860-767-0147
Practice Address - Fax:860-767-0148
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CTLMSW44421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health