Provider Demographics
NPI:1194035030
Name:PIETERSE, PORTIA LUCILLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PORTIA
Middle Name:LUCILLE
Last Name:PIETERSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HACKETT BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3462
Mailing Address - Country:US
Mailing Address - Phone:518-262-5511
Mailing Address - Fax:518-262-7035
Practice Address - Street 1:25 HACKETT BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3462
Practice Address - Country:US
Practice Address - Phone:518-262-5511
Practice Address - Fax:518-262-7035
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018848103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical