Provider Demographics
NPI:1386755023
Name:PORTER, THERESA ANN (LICSW)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
Last Name:PORTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SOUTH 2ND STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5729
Mailing Address - Country:US
Mailing Address - Phone:701-258-3780
Mailing Address - Fax:701-258-6431
Practice Address - Street 1:600 SOUTH 2ND STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5729
Practice Address - Country:US
Practice Address - Phone:701-258-3780
Practice Address - Fax:701-258-6431
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20201041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26413OtherBCBS
NDBCBS 26413OtherMSW,LICSW
NDPIN 19146Medicaid
ND19146Medicaid
HP65337OtherHEALTH PARTNERS
NDPIN 19146Medicaid
NDBCBS 26413OtherMSW,LICSW