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NPI Code Detail

MEDICARE: REBECCA L PORTA LCSW

MEDICARE: REBECCA L PORTA LCSW
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
11041C0700XClinical Social WorkerSW 5144FL

General Provider Information

NPI Number : 1225072986
Entity Type Code : Individual
Provider Name (Legal Business Name) : REBECCA L PORTA LCSW
Provider Business Mailing Address
First Line : 7680 TIMBERLINE ROAD NE
Second Line :
City : KALKASKA
State : MI
Zip : 49646
Country : US
Telephone Number : 321-441-5735
Fax Number :
Provider Business Practice Location Address
First Line : 1680 HARTWICK PINES RD
Second Line :
City : GRAYLING
State : MI
Zip : 49738-9237
Country : US
Telephone Number : 989-344-2002
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2006
Last Update Date : 12/11/2012

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