Provider Demographics
NPI:1063628519
Name:PORTER, SUSAN RENEE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:PORTER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4231 SHENANDOAH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3512
Mailing Address - Country:US
Mailing Address - Phone:314-517-5644
Mailing Address - Fax:314-664-7848
Practice Address - Street 1:4231 SHENANDOAH AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-3512
Practice Address - Country:US
Practice Address - Phone:314-517-5644
Practice Address - Fax:314-664-7848
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0035811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical