Provider Demographics
NPI:1467998518
Name:PORTER, SHANNON L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-1297
Mailing Address - Country:US
Mailing Address - Phone:614-752-0333
Mailing Address - Fax:
Practice Address - Street 1:2200 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-1297
Practice Address - Country:US
Practice Address - Phone:614-752-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7313103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic