Provider Demographics
NPI:1578691606
Name:PORTNOY, CHARLENE MAYSON (LICSW LMFT)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:MAYSON
Last Name:PORTNOY
Suffix:
Gender:F
Credentials:LICSW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD STE 355
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1730
Mailing Address - Country:US
Mailing Address - Phone:612-760-2859
Mailing Address - Fax:612-926-8915
Practice Address - Street 1:6465 WAYZATA BLVD STE 355
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1730
Practice Address - Country:US
Practice Address - Phone:612-760-2859
Practice Address - Fax:612-926-8915
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN017691041C0700X
MN0361106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN158T5P0OtherBLUE CROSS BLUE SHIELD
MN6299260OtherMEDICA