Provider Demographics
NPI:1194364778
Name:PORTER, CHRISTIAN WAYNE (BCBA)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:WAYNE
Last Name:PORTER
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR STE D101
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8905
Mailing Address - Country:US
Mailing Address - Phone:801-683-1062
Mailing Address - Fax:801-295-5537
Practice Address - Street 1:322 DUPONT DR STE C
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-1764
Practice Address - Country:US
Practice Address - Phone:317-334-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-19-401227103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300033976Medicaid