Provider Demographics
NPI:1710794425
Name:PORTER, ROBERT EDWIN III (PSYD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWIN
Last Name:PORTER
Suffix:III
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HARGER RD STE 600
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1820
Mailing Address - Country:US
Mailing Address - Phone:901-734-6460
Mailing Address - Fax:
Practice Address - Street 1:1200 HARGER RD STE 600
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1820
Practice Address - Country:US
Practice Address - Phone:901-734-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.011347103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical