Healthcare Provider Details

I. General information

NPI: 1548808579
Provider Name (Legal Business Name): ROBERT ALLEN PORTER LADC/CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2019
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 OYSTER RIVER RD
WARREN ME
04864-4248
US

IV. Provider business mailing address

191 OYSTER RIVER RD
WARREN ME
04864-4248
US

V. Phone/Fax

Practice location:
  • Phone: 207-886-4443
  • Fax:
Mailing address:
  • Phone: 207-886-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC8030
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: