Healthcare Provider Details

I. General information

NPI: 1659651222
Provider Name (Legal Business Name): MONIQUE PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20303 KELLY RD
DETROIT MI
48225-1206
US

IV. Provider business mailing address

20303 KELLY RD
DETROIT MI
48225-1206
US

V. Phone/Fax

Practice location:
  • Phone: 313-245-7000
  • Fax:
Mailing address:
  • Phone: 313-245-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6801091669
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801091669
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801091669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: