Provider Demographics
NPI:1639988140
Name:PORCELLI, BRIAN (LSW)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PORCELLI
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 S 46TH ST APT 301
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3732
Mailing Address - Country:US
Mailing Address - Phone:609-610-3278
Mailing Address - Fax:
Practice Address - Street 1:340 MONTAGE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1707
Practice Address - Country:US
Practice Address - Phone:570-346-3686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW141629104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty