Provider Demographics
NPI:1518412469
Name:GANPOT, PORTIA (MSW, LCSWA)
Entity type:Individual
Prefix:MRS
First Name:PORTIA
Middle Name:
Last Name:GANPOT
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9921 SWEET OAK DR APT 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-7363
Mailing Address - Country:US
Mailing Address - Phone:252-414-6078
Mailing Address - Fax:
Practice Address - Street 1:2003 E NC HIGHWAY 54
Practice Address - Street 2:SUITE C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-2482
Practice Address - Country:US
Practice Address - Phone:919-682-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0108391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical