Provider Demographics
NPI:1396855441
Name:PORTER, CANDICE FERN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:FERN
Last Name:PORTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WESTON AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-1833
Mailing Address - Country:US
Mailing Address - Phone:617-786-0137
Mailing Address - Fax:617-479-4798
Practice Address - Street 1:36 WESTON AVE
Practice Address - Street 2:36 WESTON AVE
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02170-1833
Practice Address - Country:US
Practice Address - Phone:617-786-0137
Practice Address - Fax:617-479-4798
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health