Provider Demographics
NPI:1841641420
Name:PORTER, JULIA AMANDA (MA, ATC, LAT, CSCS)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:AMANDA
Last Name:PORTER
Suffix:
Gender:F
Credentials:MA, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:AMANDA
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:481 BURRAGE RD NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2623
Mailing Address - Country:US
Mailing Address - Phone:704-786-4161
Mailing Address - Fax:704-782-7539
Practice Address - Street 1:481 BURRAGE RD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2623
Practice Address - Country:US
Practice Address - Phone:704-786-4161
Practice Address - Fax:704-782-7539
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-25
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist