Healthcare Provider Details

I. General information

NPI: 1740361732
Provider Name (Legal Business Name): DANIEL B. PORTER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4248 OLD CAVE SPRING RD
ROANOKE VA
24018-3417
US

IV. Provider business mailing address

PO BOX 20071
ROANOKE VA
24018-0008
US

V. Phone/Fax

Practice location:
  • Phone: 540-989-5640
  • Fax: 540-989-6587
Mailing address:
  • Phone: 540-989-5640
  • Fax: 540-989-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701000644
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: