Provider Demographics
NPI:1639653306
Name:PORTER, ROBERT
Entity Type:Individual
Prefix:MR
First Name:ROBERT
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 1:11225 N 28TH DR STE C115G
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5606
Mailing Address - Country:US
Mailing Address - Phone:702-610-6375
Mailing Address - Fax:
Practice Address - Street 1:11225 N 28TH DR STE C115G
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5606
Practice Address - Country:US
Practice Address - Phone:702-610-6375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician