Provider Demographics
NPI:1881246338
Name:PORTER, VAN LAWRENCE (MA, CDCA,QMHS, CMS)
Entity type:Individual
Prefix:
First Name:VAN LAWRENCE
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:MA, CDCA,QMHS, CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017
Mailing Address - Country:US
Mailing Address - Phone:440-234-2006
Mailing Address - Fax:
Practice Address - Street 1:3500 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3734
Practice Address - Country:US
Practice Address - Phone:216-407-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 251B00000X, 251S00000X
OHCDCA.172699101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health