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NPI Code Detail

MEDICARE: GWENETH PORTER

MEDICARE: GWENETH PORTER
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
1106S00000XBehavior Technician
2101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1104402437
Entity Type Code : Individual
Provider Name (Legal Business Name) : GWENETH PORTER
Provider Business Mailing Address
First Line : 1500 W SHURE DR
Second Line :
City : ARLINGTON HEIGHTS
State : IL
Zip : 60004-1443
Country : US
Telephone Number : 847-271-8162
Fax Number :
Provider Business Practice Location Address
First Line : 1500 W SHURE DR
Second Line :
City : ARLINGTON HEIGHTS
State : IL
Zip : 60004-1443
Country : US
Telephone Number : 857-271-8162
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/18/2021
Last Update Date : 09/15/2022

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Directions to “ GWENETH PORTER ” Practice Location

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