Provider Demographics
NPI:1750992400
Name:PORTNER, LAURA (PHD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PORTNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 CRESTWAY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-5406
Mailing Address - Country:US
Mailing Address - Phone:979-251-4679
Mailing Address - Fax:
Practice Address - Street 1:1106 CLAYTON LN STE 522W
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2489
Practice Address - Country:US
Practice Address - Phone:512-400-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37755103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling