Healthcare Provider Details

I. General information

NPI: 1215043393
Provider Name (Legal Business Name): CAROL L. PORTER EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 UPPER MONTCLAIR PLZ SUITE #27
UPPER MONTCLAIR NJ
07043-1343
US

IV. Provider business mailing address

51 UPPER MONTCLAIR PLZ SUITE #27
UPPER MONTCLAIR NJ
07043-1343
US

V. Phone/Fax

Practice location:
  • Phone: 973-783-4511
  • Fax: 973-783-2844
Mailing address:
  • Phone: 973-783-4511
  • Fax: 973-783-2844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberSI 1459
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: