Provider Demographics
NPI:1710167218
Name:PORTNER, CASEY MARK
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:MARK
Last Name:PORTNER
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 1:919 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2009
Mailing Address - Country:US
Mailing Address - Phone:954-763-2030
Mailing Address - Fax:954-467-5844
Practice Address - Street 1:919 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-2009
Practice Address - Country:US
Practice Address - Phone:954-763-2030
Practice Address - Fax:954-467-5844
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor