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General NPI Number Information
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NPI Number | 1265927503
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Entity Type | Organization
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Legal Business Name | ALYSSA PORTER LLC
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Dates
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Enumeration Date | 06/28/2018
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Last Update Date | 06/28/2018
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Provider Practice Location Address
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Address Line | 3310 E DOUGLAS AVE
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City | WICHITA
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State | KS
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Zip | 67208-3314
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Country | US
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Telephone | 316-617-9831
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Fax |
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Provider Business Mailing Address
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Address Line | 3310 E DOUGLAS AVE
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City | WICHITA
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State | KS
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Zip | 67208-3314
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Country | US
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Telephone | 316-617-9831
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Fax |
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Authorized Official
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Title or Position | THERAPIT/PROVIDER
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Name | MISS ALYSSA JANE PORTER
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Credential | LSCSW, LMAC
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Telephone | 316-617-9831
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 4792
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License Number State | KS
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