Provider Demographics
NPI:1720501414
Name:PORTER, OLIVIA C
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:C
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 CLINTON PLACE
Mailing Address - Street 2:UNIT 301
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-2215
Mailing Address - Country:US
Mailing Address - Phone:708-557-2458
Mailing Address - Fax:
Practice Address - Street 1:414 CLINTON PL APT 301
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-2215
Practice Address - Country:US
Practice Address - Phone:708-557-2458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist