Provider Demographics
NPI:1841218443
Name:PORTER, SCOTT S (PHD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:S
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 1:1614 MAHAN CENTER BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5475
Mailing Address - Country:US
Mailing Address - Phone:850-765-7292
Mailing Address - Fax:850-765-5938
Practice Address - Street 1:1614 MAHAN CENTER BLVD STE 104
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5475
Practice Address - Country:US
Practice Address - Phone:850-765-7292
Practice Address - Fax:850-765-5938
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY101292084N0400X, 103TC0700X, 103G00000X
ND3742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13124Medicaid
MN372126400Medicaid
FLJJ944ZMedicaid
MN372126400Medicaid