Provider Demographics
NPI:1417602210
Name:PORCORO, TICA LOUISE
Entity Type:Individual
Prefix:
First Name:TICA
Middle Name:LOUISE
Last Name:PORCORO
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 1:69 WELLING RD
Mailing Address - Street 2:
Mailing Address - City:SLATE HILL
Mailing Address - State:NY
Mailing Address - Zip Code:10973-4111
Mailing Address - Country:US
Mailing Address - Phone:845-800-5566
Mailing Address - Fax:
Practice Address - Street 1:69 WELLING RD
Practice Address - Street 2:
Practice Address - City:SLATE HILL
Practice Address - State:NY
Practice Address - Zip Code:10973-4111
Practice Address - Country:US
Practice Address - Phone:845-800-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY860535174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist