Provider Demographics
NPI:1053144675
Name:PORTER, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6841 SE BOISE STREET
Mailing Address - Street 2:#A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206
Mailing Address - Country:US
Mailing Address - Phone:971-359-3276
Mailing Address - Fax:
Practice Address - Street 1:833 SE MAIN STREET
Practice Address - Street 2:#220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:971-359-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-TA-10201665224900000X, 405300000X
ORBAP-FA-10213306247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No405300000XOther Service ProvidersPrevention Professional