Provider Demographics
NPI:1154077816
Name:PORTER, DWIGHT WENISLOW SR (CPSS)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:WENISLOW
Last Name:PORTER
Suffix:SR
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1852 WEST GRAND BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208
Mailing Address - Country:US
Mailing Address - Phone:313-894-8444
Mailing Address - Fax:313-894-5542
Practice Address - Street 1:1852 WEST GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208
Practice Address - Country:US
Practice Address - Phone:313-894-8444
Practice Address - Fax:313-894-5542
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist