Provider Demographics
NPI:1710057724
Name:PORTER, MARY LYNN (LCSW, LPC, LMFT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYNN
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 10803
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77206
Mailing Address - Country:US
Mailing Address - Phone:713-306-2738
Mailing Address - Fax:281-242-0111
Practice Address - Street 1:101 SOUTHWESTERN BOULEVARD
Practice Address - Street 2:SUITE 113
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478
Practice Address - Country:US
Practice Address - Phone:713-306-2738
Practice Address - Fax:281-242-0111
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06462101YP2500X
TX0008711041C0700X
TX002372106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX484035OtherVALUE OPTIONS ID #
TX86409QOtherBCBS ID #