MEDICARE: CHAD MICHAEL PORTER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW33747	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649590308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD MICHAEL PORTER LCSW

Provider Business Mailing Address
First Line	:	855 N CAPITAL AVE STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3405
Country	:	US
Telephone Number	:	208-552-0855
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 N CAPITAL AVE STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3405
Country	:	US
Telephone Number	:	208-552-0855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2010
Last Update Date	:	01/17/2025

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