Provider Demographics
NPI:1700391067
Name:PORTER, TIMOTHY PAUL (LCSW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PAUL
Last Name:PORTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50373
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82605-0373
Mailing Address - Country:US
Mailing Address - Phone:307-439-6424
Mailing Address - Fax:
Practice Address - Street 1:933 W 14TH ST STE 6
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3561
Practice Address - Country:US
Practice Address - Phone:307-439-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMBTSWO-443241041C0700X
MTBBH-SWLC-LIC-504471041C0700X
WASC612824841041C0700X
WYLCSW-14651041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPCSW-905OtherPCSW