Provider Demographics
NPI:1962587865
Name:PORTER, LEORA LAWRENCE (LCSW)
Entity type:Individual
Prefix:
First Name:LEORA
Middle Name:LAWRENCE
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 1:1060 SANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4657
Mailing Address - Country:US
Mailing Address - Phone:757-464-6497
Mailing Address - Fax:
Practice Address - Street 1:3432 VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-4420
Practice Address - Country:US
Practice Address - Phone:757-437-3249
Practice Address - Fax:757-437-3249
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040014211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0049455395Medicaid
VAO87022OtherOPTIMA PROVIDER NUMBER
VA108496OtherANTHEM PROVIDER NUMBER