Healthcare Provider Details

I. General information

NPI: 1265946776
Provider Name (Legal Business Name): JUSTIN PORTER MSW, LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 W CHURCH ST STE 318
NEWARK OH
43055-5050
US

IV. Provider business mailing address

380 W NATIONAL DR APT A
NEWARK OH
43055-4845
US

V. Phone/Fax

Practice location:
  • Phone: 740-281-1777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.1600960
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: