Provider Demographics
NPI:1841826484
Name:PORTWOOD, MONIQUE NE'SHA (MA, LPC-IT)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:NE'SHA
Last Name:PORTWOOD
Suffix:
Gender:F
Credentials:MA, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W MEINECKE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3251
Mailing Address - Country:US
Mailing Address - Phone:414-334-1716
Mailing Address - Fax:
Practice Address - Street 1:2600 N MAYFAIR RD STE 650
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1322
Practice Address - Country:US
Practice Address - Phone:414-771-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4164226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional