Provider Demographics
NPI:1629057823
Name:LAPORTA, GRETCHEN MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:MARIE
Last Name:LAPORTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:GRETCHEN
Other - Middle Name:MARIE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 690181
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7003
Mailing Address - Country:US
Mailing Address - Phone:704-283-2900
Mailing Address - Fax:
Practice Address - Street 1:1501 N CHARLOTTE AVE # A239
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2525
Practice Address - Country:US
Practice Address - Phone:704-283-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCOO44181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005126Medicaid
NC6005126Medicaid