Provider Demographics
NPI:1619549557
Name:RENTERIA, PORFIRIA ANDRADE
Entity Type:Individual
Prefix:MRS
First Name:PORFIRIA
Middle Name:ANDRADE
Last Name:RENTERIA
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 1:120 SPLIT REIN DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-4110
Mailing Address - Country:US
Mailing Address - Phone:707-624-5510
Mailing Address - Fax:
Practice Address - Street 1:120 SPLIT REIN DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-4110
Practice Address - Country:US
Practice Address - Phone:707-624-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst