Provider Demographics
NPI:1235472366
Name:PORTER, MELINDA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MELINDA
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 1:630 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6258
Mailing Address - Country:US
Mailing Address - Phone:817-733-7206
Mailing Address - Fax:281-925-0615
Practice Address - Street 1:630 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6258
Practice Address - Country:US
Practice Address - Phone:817-733-7206
Practice Address - Fax:281-925-0615
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional