Healthcare Provider Details

I. General information

NPI: 1821006909
Provider Name (Legal Business Name): BENJAMIN PORTER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 CARLISLE BLVD NE SUITE E
ALBUQUERQUE NM
87110-5658
US

IV. Provider business mailing address

1400 CARLISLE BLVD NE SUITE E
ALBUQUERQUE NM
87110-5658
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-8890
  • Fax: 505-266-0541
Mailing address:
  • Phone: 505-255-8890
  • Fax: 505-266-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number487
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: