Healthcare Provider Details

I. General information

NPI: 1245062397
Provider Name (Legal Business Name): TIMOTHY RAY PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 COUNTY ROAD 411
PROCTORVILLE OH
45669-9409
US

IV. Provider business mailing address

1159 COUNTY ROAD 411
PROCTORVILLE OH
45669-9409
US

V. Phone/Fax

Practice location:
  • Phone: 740-861-9171
  • Fax:
Mailing address:
  • Phone: 740-861-9171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: