Provider Demographics
NPI:1750420113
Name:PORTER, DAN KENNETH (LISW, LICDC)
Entity type:Individual
Prefix:MR
First Name:DAN
Middle Name:KENNETH
Last Name:PORTER
Suffix:
Gender:M
Credentials:LISW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9007 OLD STATE RD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9255
Mailing Address - Country:US
Mailing Address - Phone:440-286-7191
Mailing Address - Fax:
Practice Address - Street 1:8445 MUNSON RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-2410
Practice Address - Country:US
Practice Address - Phone:440-255-1700
Practice Address - Fax:440-205-2417
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI37491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical