Healthcare Provider Details

I. General information

NPI: 1609402866
Provider Name (Legal Business Name): SUSAN PORTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 N ELAM AVE STE 3E
GREENSBORO NC
27403-1129
US

IV. Provider business mailing address

509 N ELAM AVE # 3E
GREENSBORO NC
27403-1129
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-1970
  • Fax:
Mailing address:
  • Phone: 984-888-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC012765
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: