Provider Demographics
NPI:1669923397
Name:PORTER, MASON G (DPT)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:G
Last Name:PORTER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 ROBIN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5751
Mailing Address - Country:US
Mailing Address - Phone:985-542-7878
Mailing Address - Fax:985-542-4396
Practice Address - Street 1:2204 ROBIN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5751
Practice Address - Country:US
Practice Address - Phone:985-542-7878
Practice Address - Fax:985-542-4396
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist