Provider Demographics
NPI:1922148873
Name:GOTTLIEB-PORLICK, DEBORAH HELENE (LMSW, CAC)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:HELENE
Last Name:GOTTLIEB-PORLICK
Suffix:
Gender:F
Credentials:LMSW, CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-2392
Mailing Address - Country:US
Mailing Address - Phone:810-229-1630
Mailing Address - Fax:
Practice Address - Street 1:766 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2392
Practice Address - Country:US
Practice Address - Phone:810-229-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010662011041C0700X
FL19001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008978790OtherBCBSM PIN NO.