Provider Demographics
NPI:1548679517
Name:PORTER, KELLEY (LCSW)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:23 WATER ST STE 3
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-5119
Mailing Address - Country:US
Mailing Address - Phone:207-939-8566
Mailing Address - Fax:
Practice Address - Street 1:23 WATER ST STE 3
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-5119
Practice Address - Country:US
Practice Address - Phone:207-939-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC14851104100000X
MELC162151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker