Provider Demographics
NPI:1679705156
Name:PORTER, ERIN LOUISE
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:LOUISE
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 SCOTLAND YARD BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5913
Mailing Address - Country:US
Mailing Address - Phone:815-953-7697
Mailing Address - Fax:
Practice Address - Street 1:171 SCOTLAND YARD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-5913
Practice Address - Country:US
Practice Address - Phone:815-953-7697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2014-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178006244101YP2500X
FLMH 12382101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional