Healthcare Provider Details

I. General information

NPI: 1669919593
Provider Name (Legal Business Name): GLEN PORTER CMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N 1680 E STE W2
ST GEORGE UT
84790-2609
US

IV. Provider business mailing address

558 S AERIES DR
WASHINGTON UT
84780-3568
US

V. Phone/Fax

Practice location:
  • Phone: 435-227-5052
  • Fax: 435-215-4514
Mailing address:
  • Phone: 801-499-9435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9823173-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: