Provider Demographics
NPI:1124199815
Name:PORTER, GWINNE WYATT (PHD)
Entity type:Individual
Prefix:DR
First Name:GWINNE
Middle Name:WYATT
Last Name:PORTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 STONELEIGH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-2454
Mailing Address - Country:US
Mailing Address - Phone:917-747-4218
Mailing Address - Fax:
Practice Address - Street 1:667 STONELEIGH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-2454
Practice Address - Country:US
Practice Address - Phone:917-747-4218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016716103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist