MEDICARE: MRS. BRITTANI AMBER MARIE PORTER LPCC, LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	300933	MN
2	101YM0800X	Mental Health Counselor	CC02078	MN

General Provider Information

NPI Number	:	1487971016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRITTANI AMBER MARIE PORTER LPCC, LADC

Provider Business Mailing Address
First Line	:	5563 HUGO RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-2344
Country	:	US
Telephone Number	:	651-468-5036
Fax Number	:

Provider Business Practice Location Address
First Line	:	5563 HUGO RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-2344
Country	:	US
Telephone Number	:	651-465-5036
Fax Number	:

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

Provider Enumeration Date	:	04/21/2010
Last Update Date	:	05/31/2019

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