Provider Demographics
NPI:1043959844
Name:PORTER, SHAWANA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:SHAWANA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 N MATTHEWS RD APT C2
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-7049
Mailing Address - Country:US
Mailing Address - Phone:803-513-2909
Mailing Address - Fax:
Practice Address - Street 1:879 N MATTHEWS RD APT C2
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-7049
Practice Address - Country:US
Practice Address - Phone:803-513-2909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6519101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty