Provider Demographics
NPI:1386929057
Name:PORTER, LISA G (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 PIGEON ROOST RD
Mailing Address - Street 2:
Mailing Address - City:RUSH
Mailing Address - State:KY
Mailing Address - Zip Code:41168-8132
Mailing Address - Country:US
Mailing Address - Phone:606-928-6648
Mailing Address - Fax:606-928-1056
Practice Address - Street 1:645 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1704
Practice Address - Country:US
Practice Address - Phone:606-474-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252292104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100835480Medicaid