Provider Demographics
NPI:1740224799
Name:PORTEE, TARA BURTON (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:BURTON
Last Name:PORTEE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N MAIN ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-2712
Mailing Address - Country:US
Mailing Address - Phone:804-541-6708
Mailing Address - Fax:
Practice Address - Street 1:222 N MAIN ST
Practice Address - Street 2:SUITE 320
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2712
Practice Address - Country:US
Practice Address - Phone:804-541-6708
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904003636101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945280Medicaid