Provider Demographics
NPI:1194487728
Name:POR, DEJANARA
Entity Type:Individual
Prefix:
First Name:DEJANARA
Middle Name:
Last Name:POR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 TERSOLO RD
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-8629
Mailing Address - Country:US
Mailing Address - Phone:978-476-1980
Mailing Address - Fax:
Practice Address - Street 1:8 FANEUIL HALL MARKETPLACE FL 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-6114
Practice Address - Country:US
Practice Address - Phone:617-863-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician