=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104592112
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMELIA G PORTER PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2021
-----------------------------------------------------
Last Update Date | 10/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11250 SSG SIMS ST
-----------------------------------------------------
City | FORT BLISS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-240-0049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6924 ROCK CANYON DR
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79912-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-240-0049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY-005849
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------