Provider Demographics
NPI:1245313295
Name:PORTER, JUDITH L (LMP)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8421 CASCADIA AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3504
Mailing Address - Country:US
Mailing Address - Phone:206-293-2961
Mailing Address - Fax:425-379-2382
Practice Address - Street 1:1207 N 200TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3213
Practice Address - Country:US
Practice Address - Phone:206-293-2961
Practice Address - Fax:425-379-2382
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005326225700000X
WAMC60239573101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist