Healthcare Provider Details

I. General information

NPI: 1700358520
Provider Name (Legal Business Name): SYNDREA PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1146 BLAIRS FERRY RD NE STE 2
CEDAR RAPIDS IA
52402-1274
US

IV. Provider business mailing address

2037 D ST SW
CEDAR RAPIDS IA
52404-2919
US

V. Phone/Fax

Practice location:
  • Phone: 319-360-6609
  • Fax:
Mailing address:
  • Phone: 217-417-5294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.009300
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number088805
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: