Provider Demographics
NPI:1053759951
Name:PORTER, ROSEANNE ELLEN
Entity type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:ELLEN
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 SOUTH EMERYWOOD COURT
Mailing Address - Street 2:UNIT D
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117
Mailing Address - Country:US
Mailing Address - Phone:702-884-9017
Mailing Address - Fax:
Practice Address - Street 1:1109 EMERYWOOD CT
Practice Address - Street 2:UNITD
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-9041
Practice Address - Country:US
Practice Address - Phone:702-884-9017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1602971403103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst