Provider Demographics
NPI:1598494635
Name:PORTER, KENDRA (MA)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S POKEGAMA AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4296
Mailing Address - Country:US
Mailing Address - Phone:218-999-0051
Mailing Address - Fax:218-999-7020
Practice Address - Street 1:1200 S POKEGAMA AVE STE 160
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4296
Practice Address - Country:US
Practice Address - Phone:218-999-0051
Practice Address - Fax:218-999-7020
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02638101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional