MEDICARE: MS. ALICIA 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
1	253J00000X	Foster Care Agency		TX

General Provider Information

NPI Number	:	1487023024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALICIA PORTER

Provider Business Mailing Address
First Line	:	3642 HULEN PARK CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1428
Country	:	US
Telephone Number	:	817-896-5858
Fax Number	:

Provider Business Practice Location Address
First Line	:	3642 HULEN PARK CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1428
Country	:	US
Telephone Number	:	817-896-5858
Fax Number	:

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

Provider Enumeration Date	:	09/23/2015
Last Update Date	:	09/23/2015

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Directions to “ MS. ALICIA PORTER ” Practice Location

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