Basic Information
| Provider Information | |||||||||
| NPI: | 1881797868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTO | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 NEWMAN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RUMFORD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029163606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014530666 | ||||||||
| FaxNumber: | 4014539619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 ATWOOD AVE | ||||||||
| Address2: | SUITE 213 | ||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029193228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013510400 | ||||||||
| FaxNumber: | 4013510410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS00486 | RI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 30232-0 | 01 | RI | BLUE SHIELD PROVIDER # | OTHER | 204670 | 01 | RI | BLUE CHIP PROVIDER # | OTHER |