Provider Demographics
NPI:1235912718
Name:TOLKIN, PORTER ALLEGRA
Entity Type:Individual
Prefix:
First Name:PORTER
Middle Name:ALLEGRA
Last Name:TOLKIN
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 1:200 MEDICAL PLAZA DRIVEWAY UNIT 502
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA DRIVEWAY UNIT 502
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:424-465-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA115531104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health