=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639729262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARRY PORTA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2019
-----------------------------------------------------
Last Update Date | 09/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 W MAIN ST STE C
-----------------------------------------------------
City | GAYLORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49735-1885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-448-2640
-----------------------------------------------------
Fax | 989-448-2639
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 W MAIN ST STE C
-----------------------------------------------------
City | GAYLORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49735-1885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-448-2640
-----------------------------------------------------
Fax | 989-448-2639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LARRY PORTA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 989-448-2640
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------