Provider Demographics
NPI:1023536935
Name:MACEY, PORTER
Entity Type:Individual
Prefix:
First Name:PORTER
Middle Name:
Last Name:MACEY
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 1:150 E 700 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3806
Mailing Address - Country:US
Mailing Address - Phone:801-364-8080
Mailing Address - Fax:
Practice Address - Street 1:150 E 700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3806
Practice Address - Country:US
Practice Address - Phone:801-364-8080
Practice Address - Fax:801-364-8080
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10418270-3904101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health