MEDICARE: DR. CAROL L. PORTER EDD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	SI 1459	NJ

General Provider Information

NPI Number	:	1215043393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL L. PORTER EDD

Provider Business Mailing Address
First Line	:	51 UPPER MONTCLAIR PLZ
Second Line	:	SUITE #27
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-1343
Country	:	US
Telephone Number	:	973-783-4511
Fax Number	:	973-783-2844

Provider Business Practice Location Address
First Line	:	51 UPPER MONTCLAIR PLZ
Second Line	:	SUITE #27
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-1343
Country	:	US
Telephone Number	:	973-783-4511
Fax Number	:	973-783-2844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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