Basic Information
| Provider Information | |||||||||
| NPI: | 1346338357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTEOUS | ||||||||
| FirstName: | GRANT | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3298 VETERANS DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496844725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317158466 | ||||||||
| FaxNumber: | 2319432263 | ||||||||
| Practice Location | |||||||||
| Address1: | 3335 S AIRPORT RD W | ||||||||
| Address2: | STE 7B | ||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496847928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317158466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 03/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6801084473 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 6801084473 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.