Provider Demographics
NPI:1922496702
Name:PORTER, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PORTER
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 1:8072 21 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-4310
Mailing Address - Country:US
Mailing Address - Phone:586-932-2700
Mailing Address - Fax:586-932-2705
Practice Address - Street 1:8072 21 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-4310
Practice Address - Country:US
Practice Address - Phone:586-932-2700
Practice Address - Fax:586-932-2705
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISC0000622101YS0200X
MI6401010305101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool