Provider Demographics
NPI:1790931400
Name:PORTER, MANDI LASHEA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:LASHEA
Last Name:PORTER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:LASHEA
Other - Last Name:STONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:4092 MERRILLVILLE DR. APT 14105
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904
Mailing Address - Country:US
Mailing Address - Phone:707-514-5037
Mailing Address - Fax:
Practice Address - Street 1:2520 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2008
Practice Address - Country:US
Practice Address - Phone:662-244-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00010707225100000X
MS5038225100000X
CA34857225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist