Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor |
NPI | 1356793160 |
---|---|
Provider Name | Johnnie B. Porter |
First Address | Villa Rica, GA 30180-6430 |
Second Address | Atlanta, GA 30337-5609 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2016 |
Last Update Date | 28/08/2016 |