MEDICARE: DAVID M PORTNER, PH.D. PLC

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	103TC0700X	Clinical Psychologist	0810001188	VA

General Provider Information

NPI Number	:	1699215970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID M PORTNER, PH.D. PLC

Provider Business Mailing Address
First Line	:	1428 WATER MILL CIR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-1359
Country	:	US
Telephone Number	:	757-642-2567
Fax Number	:	757-233-0201

Provider Business Practice Location Address
First Line	:	1428 WATER MILL CIR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-1359
Country	:	US
Telephone Number	:	757-642-2567
Fax Number	:	757-233-0201

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID MICHAEL PORTNER
Credential	:	PH.D.
Telephone Number	:	757-642-2567

Provider Enumeration Date	:	03/06/2017
Last Update Date	:	03/06/2017

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