Provider Demographics
NPI:1790477180
Name:PORTERS HEADSPACE
Entity Type:Organization
Organization Name:PORTERS HEADSPACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:810-293-5063
Mailing Address - Street 1:PO BOX 320797
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-0014
Mailing Address - Country:US
Mailing Address - Phone:810-293-5063
Mailing Address - Fax:
Practice Address - Street 1:4212 LENNON RD STE 1
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1080
Practice Address - Country:US
Practice Address - Phone:810-293-5063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-23
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty