Provider Demographics
NPI:1801858329
Name:PORTER, SHANE C (LMHC)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:C
Last Name:PORTER
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:939 BOLTON RD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8403
Mailing Address - Country:US
Mailing Address - Phone:386-423-9161
Mailing Address - Fax:386-423-3094
Practice Address - Street 1:265 N CAUSEWAY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5239
Practice Address - Country:US
Practice Address - Phone:386-423-9161
Practice Address - Fax:386-423-3094
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional