MEDICARE: MRS. PORTIA GANPOT MSW, LCSWA

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	1041C0700X	Clinical Social Worker	P010839	NC

General Provider Information

NPI Number	:	1518412469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PORTIA GANPOT MSW, LCSWA

Provider Business Mailing Address
First Line	:	9921 SWEET OAK DR APT 102
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-7363
Country	:	US
Telephone Number	:	252-414-6078
Fax Number	:

Provider Business Practice Location Address
First Line	:	2003 E NC HIGHWAY 54
Second Line	:	SUITE C
City	:	DURHAM
State	:	NC
Zip	:	27713-2482
Country	:	US
Telephone Number	:	919-682-5300
Fax Number	:

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

Provider Enumeration Date	:	08/22/2016
Last Update Date	:	08/22/2016

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