Provider Demographics
NPI:1336462068
Name:PORTER, DARREN MICHAEL (CSAC)
Entity Type:Individual
Prefix:MR
First Name:DARREN
Middle Name:MICHAEL
Last Name:PORTER
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2422 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6105
Mailing Address - Country:US
Mailing Address - Phone:262-549-6600
Mailing Address - Fax:920-445-0174
Practice Address - Street 1:2979 ALLIED ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5567
Practice Address - Country:US
Practice Address - Phone:920-337-6740
Practice Address - Fax:920-337-6741
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15865-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15865-132OtherCLINICAL SUBSTANCE ABUSE COUNSELOR