Provider Demographics
NPI:1780172569
Name:CHARLENE PORTNOY LLC
Entity type:Organization
Organization Name:CHARLENE PORTNOY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICSW, LMFT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:MAYSON
Authorized Official - Last Name:PORTNOY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:612-760-2859
Mailing Address - Street 1:6465 WAYZATA BLVD STE 355
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1730
Mailing Address - Country:US
Mailing Address - Phone:612-760-2859
Mailing Address - Fax:612-926-8915
Practice Address - Street 1:6465 WAYZATA BLVD STE 355
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1730
Practice Address - Country:US
Practice Address - Phone:612-760-2859
Practice Address - Fax:612-926-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN017691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty