Provider Demographics
NPI:1528372083
Name:PORTER-WILSON, GEORGENA WILLENA
Entity type:Individual
Prefix:
First Name:GEORGENA
Middle Name:WILLENA
Last Name:PORTER-WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 NAPIER DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-6087
Mailing Address - Country:US
Mailing Address - Phone:931-223-8071
Mailing Address - Fax:
Practice Address - Street 1:154 NAPIER DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401
Practice Address - Country:US
Practice Address - Phone:931-223-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health