Basic Information
Provider Information | |||||||||
NPI: | 1114965951 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PORTER | ||||||||
FirstName: | HARRY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LHMC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2944 PENNSYLVANIA AVE | ||||||||
Address2: |   | ||||||||
City: | MARIANNA | ||||||||
State: | FL | ||||||||
PostalCode: | 324482741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8507470420 | ||||||||
FaxNumber: | 8507692366 | ||||||||
Practice Location | |||||||||
Address1: | 2944 PENNSYLVANIA AVE | ||||||||
Address2: |   | ||||||||
City: | MARIANNA | ||||||||
State: | FL | ||||||||
PostalCode: | 324482738 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8507470420 | ||||||||
FaxNumber: | 8507692366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH8292 | FL | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | Z090C | 01 | FL | BCBS | OTHER | 7240850 | 01 | FL | AETNA | OTHER |