Healthcare Provider Details

I. General information

NPI: 1639604374
Provider Name (Legal Business Name): NATHAN ALLRED PORTER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 S 550 E STE 220
OREM UT
84097-7797
US

IV. Provider business mailing address

1429 S 550 E STE 220
OREM UT
84097-7797
US

V. Phone/Fax

Practice location:
  • Phone: 385-325-1658
  • Fax:
Mailing address:
  • Phone: 385-325-1658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10829210-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10829210-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: