Provider Demographics
NPI:1245415215
Name:PORTER, AMON OLU (PHD, LCSW)
Entity Type:Individual
Prefix:MR
First Name:AMON
Middle Name:OLU
Last Name:PORTER
Suffix:
Gender:M
Credentials:PHD, LCSW
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 14306
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94614-2306
Mailing Address - Country:US
Mailing Address - Phone:510-932-3678
Mailing Address - Fax:510-397-6292
Practice Address - Street 1:675 HEGENBERGER ROAD
Practice Address - Street 2:#214
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-1973
Practice Address - Country:US
Practice Address - Phone:510-932-3678
Practice Address - Fax:510-397-6292
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW224801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical