MEDICARE: LATISHA DENISE PORTER MS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	OK
2	101YM0800X	Mental Health Counselor	OK
3	101YP2500X	Professional Counselor	OK

General Provider Information

NPI Number	:	1356653257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATISHA DENISE PORTER MS

Provider Business Mailing Address
First Line	:	920 NW 109TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-6908
Country	:	US
Telephone Number	:	405-200-3582
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 NW 109TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-6908
Country	:	US
Telephone Number	:	405-200-3582
Fax Number	:

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

Provider Enumeration Date	:	07/08/2010
Last Update Date	:	07/08/2010

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