Provider Demographics
NPI:1114153012
Name:PORTLOCK, VAN DAVID
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:DAVID
Last Name:PORTLOCK
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 1:730 EDDY ST
Mailing Address - Street 2:ROOM 204
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-7846
Mailing Address - Country:US
Mailing Address - Phone:415-353-5655
Mailing Address - Fax:415-673-1266
Practice Address - Street 1:730 EDDY ST
Practice Address - Street 2:ROOM 204
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-7846
Practice Address - Country:US
Practice Address - Phone:415-353-5655
Practice Address - Fax:415-673-1266
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator