Provider Demographics
NPI:1508594961
Name:PORTICO ERC, LLC
Entity Type:Organization
Organization Name:PORTICO ERC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:RAYANNE
Authorized Official - Last Name:CICHOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:304-288-7928
Mailing Address - Street 1:245 WAITMAN ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-7545
Mailing Address - Country:US
Mailing Address - Phone:304-288-7928
Mailing Address - Fax:
Practice Address - Street 1:1253 CANYON RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-9273
Practice Address - Country:US
Practice Address - Phone:304-898-8389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty