MEDICARE: CARLA PORTER-WHITE L.C.P.C.

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	101YP2500X	Professional Counselor	180.009984	IL

General Provider Information

NPI Number	:	1922320019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA PORTER-WHITE L.C.P.C.

Provider Business Mailing Address
First Line	:	19710 GOVERNORS HWY STE 9
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-2081
Country	:	US
Telephone Number	:	708-955-0171
Fax Number	:

Provider Business Practice Location Address
First Line	:	19710 GOVERNORS HWY STE 9
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-2081
Country	:	US
Telephone Number	:	708-955-0171
Fax Number	:

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

Provider Enumeration Date	:	02/17/2010
Last Update Date	:	07/06/2016

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