=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497722508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA IRENE PORTER PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2006
-----------------------------------------------------
Last Update Date | 08/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CENTER FOR PERSONAL DEVELOPMENT WASHINGTON ROAD
-----------------------------------------------------
City | WEST POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-938-3022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280B BOWMAN LOOP
-----------------------------------------------------
City | WEST POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10996-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-859-4236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 993
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------