Provider Demographics
NPI:1013931187
Name:PORTER, PHIL T (PSYCHOLOGIST)
Entity Type:Individual
Prefix:MR
First Name:PHIL
Middle Name:T
Last Name:PORTER
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1229 C AVENUE EAST
Mailing Address - Street 2:#300
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577
Mailing Address - Country:US
Mailing Address - Phone:641-672-3159
Mailing Address - Fax:641-672-3259
Practice Address - Street 1:1229 C AVE E
Practice Address - Street 2:#300
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-4246
Practice Address - Country:US
Practice Address - Phone:641-672-3159
Practice Address - Fax:641-672-3259
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA00095103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist