MEDICARE: DONTHAN PORTER JR

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1891273090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONTHAN PORTER JR

Provider Business Mailing Address
First Line	:	4920 SAPPHIRE LIGHT ST
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89081-3036
Country	:	US
Telephone Number	:	702-809-0576
Fax Number	:

Provider Business Practice Location Address
First Line	:	5909 VICTORY POINT ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-3024
Country	:	US
Telephone Number	:	702-789-8466
Fax Number	:

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

Provider Enumeration Date	:	07/31/2018
Last Update Date	:	07/31/2018

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Directions to “ DONTHAN PORTER JR ” Practice Location

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