Provider Demographics
NPI:1174102891
Name:PORTER, BETHANY (LCSW)
Entity type:Individual
Prefix:
First Name:BETHANY
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 1:2161 OLD HIGHWAY 13
Mailing Address - Street 2:
Mailing Address - City:EQUALITY
Mailing Address - State:IL
Mailing Address - Zip Code:62934-2035
Mailing Address - Country:US
Mailing Address - Phone:618-384-8055
Mailing Address - Fax:
Practice Address - Street 1:2161 OLD HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:EQUALITY
Practice Address - State:IL
Practice Address - Zip Code:62934-2035
Practice Address - Country:US
Practice Address - Phone:618-384-8055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149023108101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health