Provider Demographics
NPI:1346862000
Name:PORTALATIN, LIZANDRA M (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:LIZANDRA
Middle Name:M
Last Name:PORTALATIN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WALNUT AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1269
Mailing Address - Country:US
Mailing Address - Phone:732-454-7810
Mailing Address - Fax:
Practice Address - Street 1:100 WALNUT AVE STE 210
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1269
Practice Address - Country:US
Practice Address - Phone:732-454-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00529000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health