Healthcare Provider Details

I. General information

NPI: 1912977182
Provider Name (Legal Business Name): KATHERINE DIANE PORTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 W 6200 S
KEARNS UT
84118-3725
US

IV. Provider business mailing address

941 E 1300 S
SALT LAKE CITY UT
84105-1856
US

V. Phone/Fax

Practice location:
  • Phone: 801-963-4395
  • Fax:
Mailing address:
  • Phone: 801-703-4557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5920823501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: