Provider Demographics
NPI:1902228109
Name:PORRAS, GEORGINA
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:PORRAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-0070
Mailing Address - Country:US
Mailing Address - Phone:575-882-6101
Mailing Address - Fax:575-882-6926
Practice Address - Street 1:1301 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-8846
Practice Address - Country:US
Practice Address - Phone:575-882-6101
Practice Address - Fax:575-882-6926
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM082681041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool