Provider Demographics
NPI:1336777846
Name:PORTER, BRENT WILLIAM (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:WILLIAM
Last Name:PORTER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14311 REESE BLVD W STE A2
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7955
Mailing Address - Country:US
Mailing Address - Phone:704-980-0680
Mailing Address - Fax:
Practice Address - Street 1:13835 BOREN ST
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-6476
Practice Address - Country:US
Practice Address - Phone:704-912-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8994225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist