Provider Demographics
NPI:1023358694
Name:PORTER, MICHAEL EDGAR
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDGAR
Last Name:PORTER
Suffix:
Gender:M
Credentials:
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 120045
Mailing Address - Street 2:
Mailing Address - City:ANTIMONY
Mailing Address - State:UT
Mailing Address - Zip Code:84712-0045
Mailing Address - Country:US
Mailing Address - Phone:435-624-3304
Mailing Address - Fax:
Practice Address - Street 1:57 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:LOA
Practice Address - State:UT
Practice Address - Zip Code:84747
Practice Address - Country:US
Practice Address - Phone:435-624-3304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6890665-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)