Healthcare Provider Details

I. General information

NPI: 1831653302
Provider Name (Legal Business Name): DANIEL PORTICE PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 E GORHAM ST
MADISON WI
53703-1524
US

IV. Provider business mailing address

617 RIVERSIDE AVE
BURLINGTON VT
05401-1601
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-4713
  • Fax: 608-280-4707
Mailing address:
  • Phone: 802-540-8288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number244422-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0139266
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: