Provider Demographics
NPI:1902670003
Name:PORTER, MARIE DENISE (CDCA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:DENISE
Last Name:PORTER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7569 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3203
Mailing Address - Country:US
Mailing Address - Phone:440-382-0766
Mailing Address - Fax:
Practice Address - Street 1:9083 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6462
Practice Address - Country:US
Practice Address - Phone:440-255-0678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.186466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)