Provider Demographics
NPI:1841787710
Name:PORTO, AMANDA (CDPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PORTO
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 15TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-0509
Mailing Address - Country:US
Mailing Address - Phone:360-301-1524
Mailing Address - Fax:
Practice Address - Street 1:3737 N SHELTON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-9105
Practice Address - Country:US
Practice Address - Phone:360-426-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60812037101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)