Provider Demographics
NPI:1396930194
Name:PORTER, PHILIP W
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:W
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5158
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304
Mailing Address - Country:US
Mailing Address - Phone:864-582-2411
Mailing Address - Fax:864-594-0040
Practice Address - Street 1:460 LANGDON ST.
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1614
Practice Address - Country:US
Practice Address - Phone:864-582-2411
Practice Address - Fax:864-594-0040
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6536101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC121328Medicaid
SC121328Medicaid