Provider Demographics
NPI:1447423157
Name:PORTIS, CLYTE LYDIA (LCSW, LISW-CP)
Entity Type:Individual
Prefix:MRS
First Name:CLYTE
Middle Name:LYDIA
Last Name:PORTIS
Suffix:
Gender:F
Credentials:LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 41ST ST
Mailing Address - Street 2:BLDG 40709
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5918
Mailing Address - Country:US
Mailing Address - Phone:707-787-1595
Mailing Address - Fax:706-787-1099
Practice Address - Street 1:254 41ST ST
Practice Address - Street 2:BLDG 40709
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5918
Practice Address - Country:US
Practice Address - Phone:707-787-1595
Practice Address - Fax:706-787-1099
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW003792104100000X, 1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW003792OtherGA SOCIAL WORK LICENSURE