Provider Demographics
NPI:1295054971
Name:LOVE, PORTIA BENNETT (MED)
Entity type:Individual
Prefix:MS
First Name:PORTIA
Middle Name:BENNETT
Last Name:LOVE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 NW 92ND ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-1302
Mailing Address - Country:US
Mailing Address - Phone:405-848-7040
Mailing Address - Fax:
Practice Address - Street 1:1301 NW 92ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-1302
Practice Address - Country:US
Practice Address - Phone:405-848-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health