Provider Demographics
NPI:1215987136
Name:PORTER-RICHARD, CONNIE (LMHC)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:PORTER-RICHARD
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560875
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0875
Mailing Address - Country:US
Mailing Address - Phone:321-631-5538
Mailing Address - Fax:321-631-5154
Practice Address - Street 1:845 EXECUTIVE LN
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3528
Practice Address - Country:US
Practice Address - Phone:321-631-5538
Practice Address - Fax:321-631-5154
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3802101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health