Provider Demographics
NPI:1942399902
Name:PORTER, RICKIE L
Entity Type:Individual
Prefix:MR
First Name:RICKIE
Middle Name:L
Last Name:PORTER
Suffix:
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 1:4432 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1402
Mailing Address - Country:US
Mailing Address - Phone:323-293-5900
Mailing Address - Fax:
Practice Address - Street 1:733 HINDRY AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-3005
Practice Address - Country:US
Practice Address - Phone:310-348-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10OtherSUBSTANCE ABUSE