Provider Demographics
NPI:1326594136
Name:PORTER, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:PORTER
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:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:NE
Mailing Address - Zip Code:68071-0687
Mailing Address - Country:US
Mailing Address - Phone:402-878-2046
Mailing Address - Fax:
Practice Address - Street 1:AUGUSTINE DR. #2
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:NE
Practice Address - Zip Code:68071
Practice Address - Country:US
Practice Address - Phone:402-878-2046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1002101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)