=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053778969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON PORTER M.S., LPC, LMFT, QMH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2016
-----------------------------------------------------
Last Update Date | 01/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 CENTENNIAL BLVD STE 12
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-3378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-203-6698
-----------------------------------------------------
Fax | 541-229-1285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1717 CENTENNIAL BLVD STE 12
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-3378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-203-6698
-----------------------------------------------------
Fax | 541-229-1285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C5488
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------