Provider Demographics
NPI:1063510238
Name:PORTNER, DAVID MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:PORTNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 WATER MILL CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1359
Mailing Address - Country:US
Mailing Address - Phone:757-642-2567
Mailing Address - Fax:757-233-0201
Practice Address - Street 1:1428 WATER MILL CIR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-1359
Practice Address - Country:US
Practice Address - Phone:757-642-2567
Practice Address - Fax:757-233-0201
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007704232Medicaid
VA007704224Medicaid
VA007705557Medicaid
VA007704232Medicaid
VAC06310Medicare PIN