Provider Demographics
NPI:1295246783
Name:PORTER, ANGEL NICOLE (MA, LCMHC)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:NICOLE
Last Name:PORTER
Suffix:
Gender:F
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4944 BROWN DR
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-6259
Mailing Address - Country:US
Mailing Address - Phone:910-939-1025
Mailing Address - Fax:
Practice Address - Street 1:2920 FORESTVILLE RD STE 100-1212
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-8774
Practice Address - Country:US
Practice Address - Phone:910-939-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13428101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional