Provider Demographics
NPI:1376070441
Name:PORTER, THOMAS ALBERT (PSYS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALBERT
Last Name:PORTER
Suffix:
Gender:M
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2508
Mailing Address - Country:US
Mailing Address - Phone:216-361-4400
Mailing Address - Fax:216-361-2340
Practice Address - Street 1:6470 PEARL RD
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-2929
Practice Address - Country:US
Practice Address - Phone:440-663-0037
Practice Address - Fax:440-663-0040
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP618103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool