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General NPI Number Information
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NPI Number | 1316996689
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Entity Type | Individual
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Provider Name | RUSSELL JOSEPH PORTER M.A.
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Gender | Male
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Dates
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Enumeration Date | 05/06/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 13800 PARK BLVD SWT 200
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City | SEMINOLE
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State | FL
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Zip | 33776-3439
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Country | US
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Telephone | 727-398-9799
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Fax | 727-394-7336
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Provider Business Mailing Address
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Address Line | 3791 10TH ST NE
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City | ST PETERSBURG
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State | FL
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Zip | 33704-1609
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Country | US
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Telephone | 727-821-4156
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH3873
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License Number State | FL
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