Provider Demographics
NPI:1972834745
Name:PORRAS, CANDICE ROSIE (AA)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:ROSIE
Last Name:PORRAS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18612 SANTA ANA AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-2639
Mailing Address - Country:US
Mailing Address - Phone:909-421-7120
Mailing Address - Fax:
Practice Address - Street 1:18612 SANTA ANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-2639
Practice Address - Country:US
Practice Address - Phone:909-421-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN877OtherLA COUNTY DMH