Healthcare Provider Details

I. General information

NPI: 1568959773
Provider Name (Legal Business Name): SARA PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BAPTIST DR STE 301
MADISON MS
39110-2012
US

IV. Provider business mailing address

401 BAPTIST DR STE 301
MADISON MS
39110-2012
US

V. Phone/Fax

Practice location:
  • Phone: 601-499-0935
  • Fax: 601-499-0936
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberT-3840
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number30454
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: