Basic Information
| Provider Information | |||||||||
| NPI: | 1235337924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MS., LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 ELIZABETH ST | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014205537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783425295 | ||||||||
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| Practice Location | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | SUITE NUMBER 383 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087914976 | ||||||||
| FaxNumber: | 5087916723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.