Provider Demographics
NPI:1255449211
Name:PORTER, BETH R (MSW LCSW)
Entity type:Individual
Prefix:MS
First Name:BETH
Middle Name:R
Last Name:PORTER
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:MISS
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:820 JORDAN
Mailing Address - Street 2:#475
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-424-4271
Mailing Address - Fax:318-424-8194
Practice Address - Street 1:820 JORDAN
Practice Address - Street 2:#475
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-424-4271
Practice Address - Fax:318-424-8194
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5X168Medicare ID - Type Unspecified