MEDICARE: DR. MARVIN PORTER ED.D

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	101YM0800X	Mental Health Counselor	MH7058	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10	OTHER	FL	MARRAGE AND FAMILY
2	10	OTHER	FL	SEXUAL OFFENDER COUSELING
3	10	OTHER	FL	COUPLE COUNSELING
4	10	OTHER	FL	INDIVIDUAL THERAPY
5	10	OTHER	FL	DOMESTIC VIOLENCE
6	10	OTHER	FL	MENTAL HEALTH
7	10	OTHER	FL	DRUGS AND ALCOHOL
8	10	OTHER	FL	SUBSTANCE ABUSE

General Provider Information

NPI Number	:	1558562140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARVIN PORTER ED.D

Provider Business Mailing Address
First Line	:	1011 GRACE AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-2494
Country	:	US
Telephone Number	:	850-784-7888
Fax Number	:	850-387-1445

Provider Business Practice Location Address
First Line	:	1011 GRACE AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-2494
Country	:	US
Telephone Number	:	850-784-7888
Fax Number	:	850-387-1445

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

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/08/2007

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