Provider Demographics
NPI:1164070256
Name:PORTNER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PORTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N LYNNHAVEN RD STE 308
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7523
Mailing Address - Country:US
Mailing Address - Phone:757-222-4944
Mailing Address - Fax:
Practice Address - Street 1:101 N LYNNHAVEN RD STE 308
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7523
Practice Address - Country:US
Practice Address - Phone:757-222-4944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health