Provider Demographics
NPI:1710005582
Name:PORTER, MARIELLEN L (CMT)
Entity Type:Individual
Prefix:MRS
First Name:MARIELLEN
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 2172-A
Mailing Address - Street 2:PINE RIDGE ROAD
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-9636
Mailing Address - Country:US
Mailing Address - Phone:570-223-2204
Mailing Address - Fax:570-223-7221
Practice Address - Street 1:RR 2 BOX 2172-A
Practice Address - Street 2:PINE RIDGE ROAD
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-9636
Practice Address - Country:US
Practice Address - Phone:570-223-2204
Practice Address - Fax:570-223-7221
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist