Provider Demographics
NPI:1932713914
Name:PORTO GUTIERREZ, WALTER IVAN (MSW, LCSW, LMSW)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:IVAN
Last Name:PORTO GUTIERREZ
Suffix:
Gender:M
Credentials:MSW, LCSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 SW 191ST AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33332-3375
Mailing Address - Country:US
Mailing Address - Phone:954-890-2191
Mailing Address - Fax:
Practice Address - Street 1:6333 SW 191ST AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33332-3375
Practice Address - Country:US
Practice Address - Phone:954-890-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-07
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1097691041C0700X
FLSW214761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical