Provider Demographics
NPI:1083800577
Name:PORTER, MICHELLE ANNQUNET
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNQUNET
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E CENTERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1134
Mailing Address - Country:US
Mailing Address - Phone:310-324-0515
Mailing Address - Fax:
Practice Address - Street 1:320 E CENTERVIEW DR
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1134
Practice Address - Country:US
Practice Address - Phone:310-324-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12901261604Other12901261604