Provider Demographics
NPI:1104668193
Name:PORTER, CHARNIKA
Entity type:Individual
Prefix:
First Name:CHARNIKA
Middle Name:
Last Name:PORTER
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 1:1514 RIVERBROOKE WAY NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-6624
Mailing Address - Country:US
Mailing Address - Phone:678-643-0885
Mailing Address - Fax:
Practice Address - Street 1:1514 RIVERBROOKE WAY NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-6624
Practice Address - Country:US
Practice Address - Phone:678-643-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician