Provider Demographics
NPI:1184144735
Name:PORTIK, AMBER MARIE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:MARIE
Last Name:PORTIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 SAMUEL DR
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-3226
Mailing Address - Country:US
Mailing Address - Phone:724-456-4453
Mailing Address - Fax:
Practice Address - Street 1:325 NEW CASTLE RD
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-2418
Practice Address - Country:US
Practice Address - Phone:800-362-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-25
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW019352104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker