Provider Demographics
NPI:1124523030
Name:PORTER, MARY SACKFIELD (CCC/SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SACKFIELD
Last Name:PORTER
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21000 EDUCATION CT
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5526
Mailing Address - Country:US
Mailing Address - Phone:703-517-9614
Mailing Address - Fax:
Practice Address - Street 1:21000 EDUCATION CT
Practice Address - Street 2:
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148-5526
Practice Address - Country:US
Practice Address - Phone:703-517-9614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2018-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202002614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist