Provider Demographics
NPI:1730437336
Name:PORTER, ANTONIA JO LYNN (MASTER OF SCIENCE)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:JO LYNN
Last Name:PORTER
Suffix:
Gender:F
Credentials:MASTER OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-1729
Mailing Address - Country:US
Mailing Address - Phone:305-432-1672
Mailing Address - Fax:
Practice Address - Street 1:546 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-1729
Practice Address - Country:US
Practice Address - Phone:305-432-1672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2032101YP2500X
VA0701010316101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005489001Medicaid
WV0005489002Medicaid