MEDICARE: STACY PORTER LPC-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	17357	TX

General Provider Information

NPI Number	:	1023799681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY PORTER LPC-S

Provider Business Mailing Address
First Line	:	2906 AUGUSTA ST
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-9368
Country	:	US
Telephone Number	:	409-429-0924
Fax Number	:

Provider Business Practice Location Address
First Line	:	2906 AUGUSTA ST
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-9368
Country	:	US
Telephone Number	:	409-429-0924
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2023
Last Update Date	:	07/27/2023

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Directions to “ STACY PORTER LPC-S” Practice Location

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