Provider Demographics
NPI:1427022300
Name:PORTELLI, MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PORTELLI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 UNIVERSITY PL
Mailing Address - Street 2:SUITE 1011
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4527
Mailing Address - Country:US
Mailing Address - Phone:917-902-4248
Mailing Address - Fax:
Practice Address - Street 1:113 UNIVERSITY PL
Practice Address - Street 2:SUITE 1011
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4527
Practice Address - Country:US
Practice Address - Phone:917-902-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054787-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02393442Medicaid
NYNB9401Medicare ID - Type Unspecified