Healthcare Provider Details

I. General information

NPI: 1609874007
Provider Name (Legal Business Name): MARYANN LANE PORTER MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 MAIN ST SUITE 4
SPARTA NJ
07871-1933
US

IV. Provider business mailing address

13 MAIN ST SUITE 4
SPARTA NJ
07871-1933
US

V. Phone/Fax

Practice location:
  • Phone: 973-729-4376
  • Fax: 973-729-4776
Mailing address:
  • Phone: 973-729-4376
  • Fax: 973-729-4776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC00140700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: