Provider Demographics
NPI:1851883326
Name:PORTER, KIRSTIN JOURNEY (RBT)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:JOURNEY
Last Name:PORTER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 LUNDVALL AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3338
Mailing Address - Country:US
Mailing Address - Phone:815-519-4763
Mailing Address - Fax:
Practice Address - Street 1:1042 LUNDVALL AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3338
Practice Address - Country:US
Practice Address - Phone:815-519-4763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-54975106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician