Basic Information
| Provider Information | |||||||||
| NPI: | 1750730842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN, LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MANN | ||||||||
| OtherFirstName: | MEGAN | ||||||||
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| OtherCredential: | RD, LPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 E HAWTHORN PKWY | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1790 NATIONS DR | ||||||||
| Address2: | SUITE 214 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600319164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 178008250 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.