Provider Demographics
NPI:1497722508
Name:PORTER, REBECCA IRENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:IRENE
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 1:280B BOWMAN LOOP
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10996-1002
Mailing Address - Country:US
Mailing Address - Phone:845-859-4236
Mailing Address - Fax:
Practice Address - Street 1:CENTER FOR PERSONAL DEVELOPMENT
Practice Address - Street 2:WASHINGTON ROAD
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996
Practice Address - Country:US
Practice Address - Phone:845-938-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN