Provider Demographics
NPI:1356793160
Name:PORTER, JOHNNIE B (M DIV, MACM)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:B
Last Name:PORTER
Suffix:
Gender:M
Credentials:M DIV, MACM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1986
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-6430
Mailing Address - Country:US
Mailing Address - Phone:678-820-6829
Mailing Address - Fax:
Practice Address - Street 1:4751 BEST RD STE 400E
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30337-5609
Practice Address - Country:US
Practice Address - Phone:678-637-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist