Doctor Name: | LAURA GUSTAFSON PORTER |
NPI Number: | 1720087901 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PHD |
License Number: | 2546(PROVISIONAL) |
Business Practice Address: | 6350 W Andrew Johnson Hwy Talbott, TN - 378778605 |
Business Phone Number: | 4235877337 |
Business Fax Number: | 4235880614 |
Mailing Address: | Department 888182, KNOXVILLE |
State: | TN |
Postal Code: | 379950001 |
Phone Number: | 8003553565 |
Fax Number: | 4237142355 |
NPI Enumeration Date: | 07/19/2005 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 2546(PROVISIONAL) |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | TN |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |