MEDICARE: MICKI PORTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	OH
2	376J00000X	Homemaker	OH
3	101YM0800X	Mental Health Counselor	OH

General Provider Information

NPI Number	:	1902617996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICKI PORTER

Provider Business Mailing Address
First Line	:	4513 COUNTY ROAD 12
Second Line	:
City	:	PROCTORVILLE
State	:	OH
Zip	:	45669-8304
Country	:	US
Telephone Number	:	740-222-9103
Fax Number	:

Provider Business Practice Location Address
First Line	:	4513 COUNTY ROAD 12
Second Line	:
City	:	PROCTORVILLE
State	:	OH
Zip	:	45669-8304
Country	:	US
Telephone Number	:	740-222-9103
Fax Number	:

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

Provider Enumeration Date	:	01/17/2025
Last Update Date	:	12/16/2025

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Directions to “ MICKI PORTER ” Practice Location

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