Provider Demographics
NPI:1013387687
Name:PORTA, NICHOLAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:PORTA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 1/2 WESLEY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1754
Mailing Address - Country:US
Mailing Address - Phone:423-529-0385
Mailing Address - Fax:423-414-2699
Practice Address - Street 1:2514 1/2 WESLEY ST STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1754
Practice Address - Country:US
Practice Address - Phone:423-529-0385
Practice Address - Fax:423-414-2699
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015033025101YP2500X
TNP0000003473103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional