Provider Demographics
NPI:1033248968
Name:PORT, ELIZABETH SUSAN (MS)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:SUSAN
Last Name:PORT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W BRADLEY RD # C109
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2638
Mailing Address - Country:US
Mailing Address - Phone:414-447-9890
Mailing Address - Fax:
Practice Address - Street 1:6040 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-447-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional