Provider Demographics
NPI:1881920403
Name:PORTER, CAMILLE
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 N GATEWAY DR STE 160
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9882
Mailing Address - Country:US
Mailing Address - Phone:435-799-3111
Mailing Address - Fax:435-799-3148
Practice Address - Street 1:169 N GATEWAY DR STE 160
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9882
Practice Address - Country:US
Practice Address - Phone:435-799-3111
Practice Address - Fax:435-799-3148
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60117603225100000X
UT7362653-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist