Provider Demographics
NPI:1881472009
Name:PORTO, STEPHANIE BLAKE (LMSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BLAKE
Last Name:PORTO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 GLEN MANOR RD
Mailing Address - Street 2:
Mailing Address - City:GLEN SPEY
Mailing Address - State:NY
Mailing Address - Zip Code:12737-5304
Mailing Address - Country:US
Mailing Address - Phone:917-331-2344
Mailing Address - Fax:
Practice Address - Street 1:16 COMMUNITY LN
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2851
Practice Address - Country:US
Practice Address - Phone:845-340-4105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121030104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker