Provider Demographics
NPI:1407150212
Name:PORTEUS, ELIZABETH ANN (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:PORTEUS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5313 PALEO PINES CIR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34951-2344
Mailing Address - Country:US
Mailing Address - Phone:772-577-3158
Mailing Address - Fax:
Practice Address - Street 1:5313 PALEO PINES CIR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34951-2344
Practice Address - Country:US
Practice Address - Phone:772-577-3158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-08
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010271235Z00000X
FLSA11437235Z00000X
MD05704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD039935300Medicaid
FL105167500Medicaid
PA1025554100001Medicaid