Healthcare Provider Details

I. General information

NPI: 1295187763
Provider Name (Legal Business Name): MONIQUE PORTER LCMHC, LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONIQUE SORENSEN

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5720 FAYETTEVILLE RD STE 202
DURHAM NC
27713-5333
US

IV. Provider business mailing address

5720 FAYETTEVILLE RD STE 202
DURHAM NC
27713-5333
US

V. Phone/Fax

Practice location:
  • Phone: 919-576-0084
  • Fax: 919-797-9922
Mailing address:
  • Phone: 919-576-0084
  • Fax: 919-797-9922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21682
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12195
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12195
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: