Provider Demographics
NPI:1821522137
Name:PORTER, MILLICENT (SLP)
Entity Type:Individual
Prefix:
First Name:MILLICENT
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3054 JACKSON LIBERTY ROAD
Mailing Address - Street 2:
Mailing Address - City:WESSON
Mailing Address - State:MS
Mailing Address - Zip Code:39191
Mailing Address - Country:US
Mailing Address - Phone:601-757-0766
Mailing Address - Fax:601-653-9590
Practice Address - Street 1:3054 JACKSON LIBERTY RD
Practice Address - Street 2:
Practice Address - City:WESSON
Practice Address - State:MS
Practice Address - Zip Code:39191-9688
Practice Address - Country:US
Practice Address - Phone:601-757-0766
Practice Address - Fax:601-653-9590
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4273235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist