Provider Demographics
NPI:1790004174
Name:PORTANENKO, LIZA (PPS)
Entity Type:Individual
Prefix:MISS
First Name:LIZA
Middle Name:
Last Name:PORTANENKO
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 S CHICKASAW TRL # 148
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7801
Mailing Address - Country:US
Mailing Address - Phone:951-265-8910
Mailing Address - Fax:
Practice Address - Street 1:225 S SWOOPE AVE STE 211
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5786
Practice Address - Country:US
Practice Address - Phone:407-928-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst