Provider Demographics
NPI:1912352709
Name:GRANGER, PORTIA M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PORTIA
Middle Name:M
Last Name:GRANGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 MORRELL CIR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8132
Mailing Address - Country:US
Mailing Address - Phone:601-434-1510
Mailing Address - Fax:
Practice Address - Street 1:156 MORRELL CIR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8132
Practice Address - Country:US
Practice Address - Phone:601-434-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC7819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health