Provider Demographics
NPI:1003233511
Name:PORTH, ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PORTH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-4029
Mailing Address - Country:US
Mailing Address - Phone:401-297-6123
Mailing Address - Fax:
Practice Address - Street 1:5 MOUNT AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-4029
Practice Address - Country:US
Practice Address - Phone:401-297-6123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISPO1212235Z00000X
MA9132235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist