Provider Demographics
NPI:1205399425
Name:PORTIS, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:PORTIS
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 1:620 E 101ST PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2242
Mailing Address - Country:US
Mailing Address - Phone:773-946-0642
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3740
Practice Address - Country:US
Practice Address - Phone:773-946-0642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor