Provider Demographics
NPI:1568635217
Name:PORTANOVA, MATILDA (MS)
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:
Last Name:PORTANOVA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-3310
Mailing Address - Country:US
Mailing Address - Phone:914-665-3736
Mailing Address - Fax:
Practice Address - Street 1:256 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-3310
Practice Address - Country:US
Practice Address - Phone:914-665-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017193-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist