Provider Demographics
NPI:1720392657
Name:PORTA, CHARLES ANTHONY IV
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:PORTA
Suffix:IV
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 1:375 89TH ST
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1802
Mailing Address - Country:US
Mailing Address - Phone:650-301-8665
Mailing Address - Fax:
Practice Address - Street 1:375 89TH ST
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1802
Practice Address - Country:US
Practice Address - Phone:650-301-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist