Provider Demographics
NPI:1821655895
Name:BUZZANGA, PORTIALYN (LCSW)
Entity Type:Individual
Prefix:
First Name:PORTIALYN
Middle Name:
Last Name:BUZZANGA
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 1:16250 HOMECOMING DR UNIT 1306
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91708-8824
Mailing Address - Country:US
Mailing Address - Phone:618-670-6219
Mailing Address - Fax:
Practice Address - Street 1:16250 HOMECOMING DR UNIT 1306
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91708-8824
Practice Address - Country:US
Practice Address - Phone:618-670-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX596161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical