Provider Demographics
NPI:1417092685
Name:PORTNOW, ELISABETH ROSE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:ROSE
Last Name:PORTNOW
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 COMMONWEALTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467
Mailing Address - Country:US
Mailing Address - Phone:617-964-5241
Mailing Address - Fax:617-730-9335
Practice Address - Street 1:82 MARLBOROUGH STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-964-5241
Practice Address - Fax:617-730-9335
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10256481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
30044Medicare ID - Type Unspecified