Provider Demographics
NPI:1710975834
Name:PORT, TAMAR JUDITH (MSS)
Entity Type:Individual
Prefix:MRS
First Name:TAMAR
Middle Name:JUDITH
Last Name:PORT
Suffix:
Gender:F
Credentials:MSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 LOCUST ST APT 34K
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4222
Mailing Address - Country:US
Mailing Address - Phone:215-530-2564
Mailing Address - Fax:
Practice Address - Street 1:1420 LOCUST ST APT 34K
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4222
Practice Address - Country:US
Practice Address - Phone:215-530-2564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW000153L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA441500Medicare UPIN