Provider Demographics
NPI:1770631160
Name:PORTER, EILEEN (OTR)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 CHARLES DEWITT WAY
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3063
Mailing Address - Country:US
Mailing Address - Phone:619-889-5829
Mailing Address - Fax:
Practice Address - Street 1:2139 CHARLES DEWITT WAY
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3063
Practice Address - Country:US
Practice Address - Phone:619-889-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 6338225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist