Provider Demographics
NPI:1326527920
Name:PORTLAND, KELLI SUE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:SUE
Last Name:PORTLAND
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 1:5 N RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08848-1654
Mailing Address - Country:US
Mailing Address - Phone:908-892-2048
Mailing Address - Fax:
Practice Address - Street 1:5 N RIDGE CT
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NJ
Practice Address - Zip Code:08848-1654
Practice Address - Country:US
Practice Address - Phone:908-892-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child