Individual
MRS. CLYTE LYDIA PORTIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW, LISW-CP
Contact information
Practice address
254 41ST ST, BLDG 40709, FORT GORDON, GA 30905-5918
(707) 787-1595
(706) 787-1099
Mailing address
254 41ST ST, BLDG 40709, FORT GORDON, GA 30905-5918
(707) 787-1595
(706) 787-1099
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
CSW003792
GA
1041C0700X
Clinical Social Worker
Primary
CSW003792
GA
1041S0200X
School Social Worker
CSW003792
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CSW003792
GA SOCIAL WORK LICENSURE
GA
Enumeration date
04/02/2008
Last updated
10/29/2013
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