Provider Demographics
NPI:1851751739
Name:PORTER, MARY MARIE (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARIE
Last Name:PORTER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:MARIE
Other - Last Name:ORLOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:5406 QUARRY ROCK RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-0835
Mailing Address - Country:US
Mailing Address - Phone:863-660-6095
Mailing Address - Fax:
Practice Address - Street 1:5406 QUARRY ROCK RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-0835
Practice Address - Country:US
Practice Address - Phone:863-660-6095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15174235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist