Provider Demographics
NPI:1619606951
Name:PORTER, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:PORTER
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 1:738 NE DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2931
Mailing Address - Country:US
Mailing Address - Phone:503-233-6090
Mailing Address - Fax:
Practice Address - Street 1:8915 SW CENTER ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6307
Practice Address - Country:US
Practice Address - Phone:503-726-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health