Provider Demographics
NPI:1063891521
Name:PORTER, EVELYN (BCBA)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 SOUTHSIDE RD
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-1409
Mailing Address - Country:US
Mailing Address - Phone:978-762-4878
Mailing Address - Fax:
Practice Address - Street 1:6 SOUTHSIDE RD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1409
Practice Address - Country:US
Practice Address - Phone:978-762-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11410348103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst