Provider Demographics
NPI:1639729262
Name:LARRY PORTA LLC
Entity Type:Organization
Organization Name:LARRY PORTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:989-448-2640
Mailing Address - Street 1:440 W MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1885
Mailing Address - Country:US
Mailing Address - Phone:989-448-2640
Mailing Address - Fax:989-448-2639
Practice Address - Street 1:440 W MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1885
Practice Address - Country:US
Practice Address - Phone:989-448-2640
Practice Address - Fax:989-448-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI006513220001Medicaid