Provider Demographics
NPI:1326468034
Name:PORTER, MICHAEL ANGELO SR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANGELO
Last Name:PORTER
Suffix:SR
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 1:3648 S BONITA ST.
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977
Mailing Address - Country:US
Mailing Address - Phone:619-995-1970
Mailing Address - Fax:
Practice Address - Street 1:3648 S BONITA ST.
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977
Practice Address - Country:US
Practice Address - Phone:619-995-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)