Provider Demographics
NPI:1558138966
Name:PORTER, ROCHLAND SHUNTA
Entity Type:Individual
Prefix:
First Name:ROCHLAND
Middle Name:SHUNTA
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 1:3025 JAMES DR NW
Mailing Address - Street 2:
Mailing Address - City:WESSON
Mailing Address - State:MS
Mailing Address - Zip Code:39191-6042
Mailing Address - Country:US
Mailing Address - Phone:601-896-6544
Mailing Address - Fax:
Practice Address - Street 1:3025 JAMES DR NW
Practice Address - Street 2:
Practice Address - City:WESSON
Practice Address - State:MS
Practice Address - Zip Code:39191-6042
Practice Address - Country:US
Practice Address - Phone:601-896-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171133101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor