Provider Demographics
NPI:1003204876
Name:PORTER, DELBERT DEWAYNE (COTA)
Entity Type:Individual
Prefix:
First Name:DELBERT
Middle Name:DEWAYNE
Last Name:PORTER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 CRUTCH CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DUNGANNON
Mailing Address - State:VA
Mailing Address - Zip Code:24245-3950
Mailing Address - Country:US
Mailing Address - Phone:276-467-1164
Mailing Address - Fax:
Practice Address - Street 1:787 CRUTCH CREEK LN
Practice Address - Street 2:
Practice Address - City:DUNGANNON
Practice Address - State:VA
Practice Address - Zip Code:24245-3950
Practice Address - Country:US
Practice Address - Phone:276-467-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000167224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant