Healthcare Provider Details

I. General information

NPI: 1114965951
Provider Name (Legal Business Name): HARRY E PORTER LHMC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2944 PENNSYLVANIA AVE
MARIANNA FL
32448-2738
US

IV. Provider business mailing address

2944 PENNSYLVANIA AVE
MARIANNA FL
32448-2741
US

V. Phone/Fax

Practice location:
  • Phone: 850-747-0420
  • Fax: 850-769-2366
Mailing address:
  • Phone: 850-747-0420
  • Fax: 850-769-2366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8292
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: