Provider Demographics
NPI:1235316571
Name:PORTER, CORLISS E (MFT)
Entity Type:Individual
Prefix:
First Name:CORLISS
Middle Name:E
Last Name:PORTER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3503
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93130-3503
Mailing Address - Country:US
Mailing Address - Phone:805-451-9419
Mailing Address - Fax:
Practice Address - Street 1:501 MARIN ST STE 202
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4266
Practice Address - Country:US
Practice Address - Phone:805-702-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 11926106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist