MEDICARE: DR. CANDICE FERN PORTER PHD

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	101YM0800X	Mental Health Counselor	4106	MA

General Provider Information

NPI Number	:	1396855441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CANDICE FERN PORTER PHD

Provider Business Mailing Address
First Line	:	36 WESTON AVE
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-1833
Country	:	US
Telephone Number	:	617-786-0137
Fax Number	:	617-479-4798

Provider Business Practice Location Address
First Line	:	36 WESTON AVE
Second Line	:	36 WESTON AVE
City	:	QUINCY
State	:	MA
Zip	:	02170-1833
Country	:	US
Telephone Number	:	617-786-0137
Fax Number	:	617-479-4798

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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