Provider Demographics
NPI:1225072986
Name:PORTA, REBECCA L (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:PORTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:PORTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7680 TIMBERLINE ROAD NE
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646
Mailing Address - Country:US
Mailing Address - Phone:321-441-5735
Mailing Address - Fax:
Practice Address - Street 1:1680 HARTWICK PINES RD
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-9237
Practice Address - Country:US
Practice Address - Phone:989-344-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 51441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical