Provider Demographics
NPI:1568515922
Name:PORTIS-PATTERSON, ALICE FAYE (MSW)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:FAYE
Last Name:PORTIS-PATTERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4606
Mailing Address - Country:US
Mailing Address - Phone:262-554-8743
Mailing Address - Fax:
Practice Address - Street 1:6939 MARINER DR
Practice Address - Street 2:SUITE C
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3938
Practice Address - Country:US
Practice Address - Phone:262-886-8702
Practice Address - Fax:262-886-8713
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI947-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI222157OtherVALUE OPTION
WI39228200Medicaid