Provider Demographics
NPI:1619216389
Name:PORTER, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 W JEFFERSON BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-8694
Mailing Address - Country:US
Mailing Address - Phone:260-486-5251
Mailing Address - Fax:260-486-5058
Practice Address - Street 1:4109 W JEFFERSON BLVD
Practice Address - Street 2:STE A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-8694
Practice Address - Country:US
Practice Address - Phone:260-486-5251
Practice Address - Fax:260-486-5058
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007078A1041C0700X
IN33006395A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health