Provider Demographics
NPI:1659309987
Name:PORTMAN, ROBERT CHARLES (PSYD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHARLES
Last Name:PORTMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1443
Mailing Address - Country:US
Mailing Address - Phone:508-238-7766
Mailing Address - Fax:508-230-5089
Practice Address - Street 1:66 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1443
Practice Address - Country:US
Practice Address - Phone:508-238-7766
Practice Address - Fax:508-230-5089
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3248103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03384OtherBC BS OF MASSACHUSETTS
MA709551OtherTUFTS HEALTH PLAN
MA0516902Medicaid
MA0516902Medicaid