Provider Demographics
NPI:1699467175
Name:PORTER, CHARLES FREDRICK
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDRICK
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8232 OCEAN TERRACE WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7457
Mailing Address - Country:US
Mailing Address - Phone:602-400-0231
Mailing Address - Fax:
Practice Address - Street 1:4480 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-2038
Practice Address - Country:US
Practice Address - Phone:702-807-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician