MEDICARE: MS. MARYANN LANE PORTER MSW, 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
1	1041C0700X	Clinical Social Worker	44SC00140700	NJ

General Provider Information

NPI Number	:	1609874007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARYANN LANE PORTER MSW, LCSW

Provider Business Mailing Address
First Line	:	13 MAIN ST
Second Line	:	SUITE 4
City	:	SPARTA
State	:	NJ
Zip	:	07871-1933
Country	:	US
Telephone Number	:	973-729-4376
Fax Number	:	973-729-4776

Provider Business Practice Location Address
First Line	:	13 MAIN ST
Second Line	:	SUITE 4
City	:	SPARTA
State	:	NJ
Zip	:	07871-1933
Country	:	US
Telephone Number	:	973-729-4376
Fax Number	:	973-729-4776

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

Provider Enumeration Date	:	07/09/2005
Last Update Date	:	07/08/2007

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