Provider Demographics
NPI:1558923466
Name:CHESTNUT, PORTER SHEA
Entity Type:Individual
Prefix:
First Name:PORTER
Middle Name:SHEA
Last Name:CHESTNUT
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 1:305 NE LOOP 820 BUSINESS TOWER 1
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:98 BRIGGS ST STE 990
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1287
Practice Address - Country:US
Practice Address - Phone:210-226-9536
Practice Address - Fax:210-924-3376
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist