Provider Demographics
NPI:1770564551
Name:PORTER, THOMAS FRIEDL (LICSW)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:FRIEDL
Last Name:PORTER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550
Mailing Address - Country:US
Mailing Address - Phone:508-765-9167
Mailing Address - Fax:508-764-2462
Practice Address - Street 1:29 PINE STREET
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550
Practice Address - Country:US
Practice Address - Phone:508-765-9167
Practice Address - Fax:508-764-2462
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA102096101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP0114701Medicare UPIN