Healthcare Provider Details

I. General information

NPI: 1316996689
Provider Name (Legal Business Name): RUSSELL JOSEPH PORTER M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 PARK BLVD SWT 200
SEMINOLE FL
33776-3439
US

IV. Provider business mailing address

3791 10TH ST NE
ST PETERSBURG FL
33704-1609
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-9799
  • Fax: 727-394-7336
Mailing address:
  • Phone: 727-821-4156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH3873
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: