Provider Demographics
NPI:1881269173
Name:KRESSE, PORTIA JEANNINE
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:JEANNINE
Last Name:KRESSE
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 1:111 BRAEBURN BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:NC
Mailing Address - Zip Code:28574-8463
Mailing Address - Country:US
Mailing Address - Phone:910-382-4198
Mailing Address - Fax:
Practice Address - Street 1:111 BRAEBURN BLVD
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:NC
Practice Address - Zip Code:28574-8463
Practice Address - Country:US
Practice Address - Phone:910-382-4198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health