Provider Demographics
NPI:1295091262
Name:PORTER, SANDRA G (LCSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:G
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 FOXHALL LN SE APT 8
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-3473
Mailing Address - Country:US
Mailing Address - Phone:404-381-6787
Mailing Address - Fax:
Practice Address - Street 1:1418 FOXHALL LN SE APT 8
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-3473
Practice Address - Country:US
Practice Address - Phone:404-381-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0013401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical