Provider Demographics
NPI:1649590308
Name:PORTER, CHAD MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
Last Name:PORTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N CAPITAL AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3405
Mailing Address - Country:US
Mailing Address - Phone:208-552-0855
Mailing Address - Fax:
Practice Address - Street 1:855 N CAPITAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3405
Practice Address - Country:US
Practice Address - Phone:208-552-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW337471041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1881708832Medicaid