Healthcare Provider Details

I. General information

NPI: 1881246338
Provider Name (Legal Business Name): VAN LAWRENCE PORTER MA, CDCA,QMHS, CMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CARNEGIE AVE
CLEVELAND OH
44115-3734
US

IV. Provider business mailing address

434 EASTLAND RD
BEREA OH
44017
US

V. Phone/Fax

Practice location:
  • Phone: 216-407-1207
  • Fax:
Mailing address:
  • Phone: 440-234-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.172699
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: