Healthcare Provider Details

I. General information

NPI: 1720087901
Provider Name (Legal Business Name): LAURA GUSTAFSON PORTER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7714 CONNER RD STE 105
POWELL TN
37849-3559
US

IV. Provider business mailing address

6350 W ANDREW JOHNSON HWY DEPT 100
TALBOTT TN
37877-8605
US

V. Phone/Fax

Practice location:
  • Phone: 865-947-6220
  • Fax: 865-512-1069
Mailing address:
  • Phone: 800-355-3565
  • Fax: 423-714-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2546(PROVISIONAL)
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP2546
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: