NPIMap

Organization Active NPI

Portis Marriage and Children Counseling Clinic, LLC

  • Professional Counselor
  • Racine, WI
National Provider Identifier
1609046788
Registry record updated Feb 15, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Professional CounselorTaxonomy code 101YP2500X
License
947-125 Issued in WI
Legal business name
PORTIS MARRIAGE AND CHILDREN COUNSELING CLINIC, LLC
Practice address
5801 Washington Ave Ste 103
Racine, WI 53406-4057
Phone
(262) 884-9734
Fax
(262) 884-9735
NPI assigned
Mar 5, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 15, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Alice Faye Portis-Patterson, MSW, LPCNPI 1568515922
Title
Clinical Director/Therapist
Phone
(262) 884-9734

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193400000X SINGLE SPECIALTY GROUP 101YP2500X 947-125 WI Primary

Addresses

Primary practice location

5801 Washington Ave Ste 103
Racine, WI 53406-4057

Mailing address

5801 Washington Ave Ste 110
Racine, WI 53406-4057
Phone (262) 884-9734

Other identifiers 1

IdentifierTypeStateIssuer
39228200MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080624000686 WI Part B Supplier - Clinic/Group Practice 8527139211 Receives reassigned benefits from 1 practitioner
Practice locations: Mount Pleasant, WI

National Provider Directory

National Provider Directory

Locations

5801 Washington Ave
Ste 110
Mount Pleasant, WI 53406
Phone (262) 884-9734

5801 Washington Ave
Ste 103
Mount Pleasant, WI 53406
Phone (262) 884-9734

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1204675200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1297728000000",
    "number": "1609046788",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5801 WASHINGTON AVE STE 110",
            "city": "RACINE",
            "state": "WI",
            "postal_code": "534064057",
            "telephone_number": "262-884-9734",
            "fax_number": "262-884-9735"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5801 WASHINGTON AVE STE 103",
            "city": "RACINE",
            "state": "WI",
            "postal_code": "534064057",
            "telephone_number": "262-884-9734",
            "fax_number": "262-884-9735"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORTIS MARRIAGE AND CHILDREN COUNSELING CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-05",
        "last_updated": "2011-02-15",
        "status": "A",
        "authorized_official_last_name": "PORTIS-PATTERSON",
        "authorized_official_first_name": "ALICE",
        "authorized_official_middle_name": "FAYE",
        "authorized_official_title_or_position": "CLINICAL DIRECTOR/THERAPIST",
        "authorized_official_telephone_number": "262-884-9734",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MSW, LPC"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Counselor, Professional",
            "state": "WI",
            "license": "947-125",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "39228200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Racine, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.