Provider Demographics
NPI:1386060325
Name:PORTER, CYNTHIA KIMBERLY
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:KIMBERLY
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 1:7317 PORTAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-7827
Mailing Address - Country:US
Mailing Address - Phone:330-966-1620
Mailing Address - Fax:
Practice Address - Street 1:7317 PORTAGE ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646
Practice Address - Country:US
Practice Address - Phone:330-966-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0900554101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid