Provider Demographics
NPI:1609575059
Name:PORTAN, MELISSA NOEMI (LMSW, MED)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NOEMI
Last Name:PORTAN
Suffix:
Gender:F
Credentials:LMSW, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 75TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-1217
Mailing Address - Country:US
Mailing Address - Phone:718-310-0890
Mailing Address - Fax:
Practice Address - Street 1:3708 91ST ST STE 3A
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7962
Practice Address - Country:US
Practice Address - Phone:718-779-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
NY119260104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker