MEDICARE: TEANA PORTER

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	104100000X	Social Worker		NY

General Provider Information

NPI Number	:	1265949432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEANA PORTER

Provider Business Mailing Address
First Line	:	155 W 21ST ST APT 6A
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10011-3235
Country	:	US
Telephone Number	:	347-873-5630
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 W 21ST ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10011-3234
Country	:	US
Telephone Number	:	347-873-5630
Fax Number	:

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

Provider Enumeration Date	:	01/09/2018
Last Update Date	:	01/09/2018

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Directions to “ TEANA PORTER ” Practice Location

Language	Start Address	Practice Location

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