Provider Demographics
NPI:1013298090
Name:ARCHER, PORTIA RENE (LCSW)
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:RENE
Last Name:ARCHER
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 1:98 N 2ND ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98 N 2ND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1254
Practice Address - Country:US
Practice Address - Phone:315-326-3555
Practice Address - Fax:315-326-3565
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP81657104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker