Provider Demographics
NPI:1720400120
Name:PORCH, MARY LOUISE HERNDON (CRC, LPCA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE HERNDON
Last Name:PORCH
Suffix:
Gender:F
Credentials:CRC, LPCA
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:HERNDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3112 WILDER ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-5228
Mailing Address - Country:US
Mailing Address - Phone:336-686-4249
Mailing Address - Fax:
Practice Address - Street 1:3801 LAKE BOONE TRL
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2934
Practice Address - Country:US
Practice Address - Phone:919-784-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health