Provider Demographics
NPI:1528187416
Name:PORCERELLI, JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PORCERELLI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MAPLE RD
Mailing Address - Street 2:SUITE 319
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6308
Mailing Address - Country:US
Mailing Address - Phone:248-646-1267
Mailing Address - Fax:
Practice Address - Street 1:300 E MAPLE RD
Practice Address - Street 2:SUITE 319
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6308
Practice Address - Country:US
Practice Address - Phone:248-646-1267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007189103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical