Provider Demographics
NPI:1588390645
Name:PORTZLINE, KALEB TODD
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:TODD
Last Name:PORTZLINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 MOOSIC HTS
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641-9507
Mailing Address - Country:US
Mailing Address - Phone:570-898-4816
Mailing Address - Fax:
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0030
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW138360104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker