Provider Demographics
NPI:1497981245
Name:PORT, VIVIAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:PORT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 PARK AVENUE
Mailing Address - Street 2:11B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0360
Mailing Address - Country:US
Mailing Address - Phone:212-744-8379
Mailing Address - Fax:212-744-8379
Practice Address - Street 1:903 PARK AVENUE
Practice Address - Street 2:11B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0360
Practice Address - Country:US
Practice Address - Phone:212-744-8379
Practice Address - Fax:212-744-8379
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR010148-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical