Provider Demographics
NPI:1699215970
Name:DAVID M PORTNER, PH.D. PLC
Entity Type:Organization
Organization Name:DAVID M PORTNER, PH.D. PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:757-642-2567
Mailing Address - Street 1:1428 WATER MILL CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1359
Mailing Address - Country:US
Mailing Address - Phone:757-642-2567
Mailing Address - Fax:757-233-0201
Practice Address - Street 1:1428 WATER MILL CIR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-1359
Practice Address - Country:US
Practice Address - Phone:757-642-2567
Practice Address - Fax:757-233-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty