Provider Demographics
NPI:1730635640
Name:RESNICK, PORTIA (ATC, BCTMB)
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:RESNICK
Suffix:
Gender:F
Credentials:ATC, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 E 24TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-3813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5707 E 24TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114
Practice Address - Country:US
Practice Address - Phone:908-812-9320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000671002255A2300X
NJ18KT00365100225700000X
HI12938225700000X
HI1362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist