MEDICARE: CASEY MARK PORTNER

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1710167218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY MARK PORTNER

Provider Business Mailing Address
First Line	:	919 NE 13TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-2009
Country	:	US
Telephone Number	:	954-763-2030
Fax Number	:	954-467-5844

Provider Business Practice Location Address
First Line	:	919 NE 13TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-2009
Country	:	US
Telephone Number	:	954-763-2030
Fax Number	:	954-467-5844

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

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	11/13/2007

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Directions to “ CASEY MARK PORTNER ” Practice Location

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