Provider Demographics
NPI:1326474610
Name:PORTANOVA, KIMBERLY A
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:PORTANOVA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2010
Mailing Address - Country:US
Mailing Address - Phone:570-878-8636
Mailing Address - Fax:
Practice Address - Street 1:104 GRANDVIEW ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-2010
Practice Address - Country:US
Practice Address - Phone:570-878-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health