Provider Demographics
NPI:1669500252
Name:PORCH, SHANNON T (SW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:T
Last Name:PORCH
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 CAMINO DEL VALLE SW
Mailing Address - Street 2:ADOBE ACRES ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6003
Mailing Address - Country:US
Mailing Address - Phone:505-877-4799
Mailing Address - Fax:
Practice Address - Street 1:1724 CAMINO DEL VALLE SW
Practice Address - Street 2:ADOBE ACRES ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6003
Practice Address - Country:US
Practice Address - Phone:505-877-4799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM 47691041S0200X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17989728Medicaid