Provider Demographics
NPI:1053957092
Name:PORTER, NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
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:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-0856
Mailing Address - Country:US
Mailing Address - Phone:847-903-5604
Mailing Address - Fax:224-788-5112
Practice Address - Street 1:600 W CAMPBELL RD STE 1
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3357
Practice Address - Country:US
Practice Address - Phone:847-903-5604
Practice Address - Fax:224-788-5112
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX536581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical