Provider Demographics
NPI:1316996689
Name:PORTER, RUSSELL JOSEPH (MA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JOSEPH
Last Name:PORTER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3791 10TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1609
Mailing Address - Country:US
Mailing Address - Phone:727-821-4156
Mailing Address - Fax:
Practice Address - Street 1:13800 PARK BLVD
Practice Address - Street 2:SWT 200
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-3439
Practice Address - Country:US
Practice Address - Phone:727-398-9799
Practice Address - Fax:727-394-7336
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3873101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health