Healthcare Provider Details

I. General information

NPI: 1518794981
Provider Name (Legal Business Name): BRYAN PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 N GRESHAM AVE APT 2
CHICAGO IL
60618-9329
US

IV. Provider business mailing address

3019 N GRESHAM AVE APT 2
CHICAGO IL
60618-9329
US

V. Phone/Fax

Practice location:
  • Phone: 773-217-0030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150.129076
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851121953
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: