Provider Demographics
NPI:1821006909
Name:PORTER, BENJAMIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5658
Mailing Address - Country:US
Mailing Address - Phone:505-255-8890
Mailing Address - Fax:505-266-0541
Practice Address - Street 1:1400 CARLISLE BLVD NE
Practice Address - Street 2:SUITE E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5658
Practice Address - Country:US
Practice Address - Phone:505-255-8890
Practice Address - Fax:505-266-0541
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM487103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist