Provider Demographics
NPI:1669503439
Name:PORIS, PAGE (LCPC)
Entity Type:Individual
Prefix:
First Name:PAGE
Middle Name:
Last Name:PORIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-2108
Mailing Address - Country:US
Mailing Address - Phone:800-428-7260
Mailing Address - Fax:847-428-7269
Practice Address - Street 1:745 S 8TH ST
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-2108
Practice Address - Country:US
Practice Address - Phone:800-428-7260
Practice Address - Fax:847-428-7269
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003462101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional