Provider Demographics
NPI:1700924016
Name:PORTER, MARY VIVIAN (LCSW LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:VIVIAN
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 MORRISS ROAD
Mailing Address - Street 2:SUITE 110B
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-3764
Mailing Address - Country:US
Mailing Address - Phone:972-420-8834
Mailing Address - Fax:
Practice Address - Street 1:6021 MORRISS ROAD
Practice Address - Street 2:SUITE 110B
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-3764
Practice Address - Country:US
Practice Address - Phone:972-420-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08339101YP2500X
TX42221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical