Provider Demographics
NPI:1164106944
Name:PORTELLI, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:PORTELLI
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 1:428 59TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3814
Mailing Address - Country:US
Mailing Address - Phone:917-584-9309
Mailing Address - Fax:
Practice Address - Street 1:428 59TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3814
Practice Address - Country:US
Practice Address - Phone:917-584-9309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services