Provider Demographics
NPI:1477321735
Name:PORTER, LISA GRAVES
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GRAVES
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 1:27608 NICOLLE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-5305
Mailing Address - Country:US
Mailing Address - Phone:586-914-1120
Mailing Address - Fax:
Practice Address - Street 1:38144 JOYCE CT
Practice Address - Street 2:
Practice Address - City:HARRISON TWP
Practice Address - State:MI
Practice Address - Zip Code:48045-3571
Practice Address - Country:US
Practice Address - Phone:503-575-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0000000000000000172V00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No172V00000XOther Service ProvidersCommunity Health Worker