Provider Demographics
NPI:1952715955
Name:GEORGE, PORSCHE
Entity Type:Individual
Prefix:
First Name:PORSCHE
Middle Name:
Last Name:GEORGE
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 1:15480 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2421
Mailing Address - Country:US
Mailing Address - Phone:760-243-8252
Mailing Address - Fax:760-245-3676
Practice Address - Street 1:15480 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2421
Practice Address - Country:US
Practice Address - Phone:760-243-8252
Practice Address - Fax:760-245-3676
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95620106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist