Provider Demographics
NPI:1811244981
Name:PORTINE- KUDLAC, ANNE CATHERINE (MA, RDT, LCADC, DRCC)
Entity type:Individual
Prefix:MS
First Name:ANNE
Middle Name:CATHERINE
Last Name:PORTINE- KUDLAC
Suffix:
Gender:F
Credentials:MA, RDT, LCADC, DRCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 EXCELSIOR PL
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-1511
Mailing Address - Country:US
Mailing Address - Phone:973-557-1545
Mailing Address - Fax:
Practice Address - Street 1:19 EXCELSIOR PL
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:NJ
Practice Address - Zip Code:07405-1511
Practice Address - Country:US
Practice Address - Phone:973-557-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2035101Y00000X
NJ37LC00121500101YA0400X
239225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist