Provider Demographics
NPI:1285006783
Name:PORTER, EUGENE
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
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 1:444 34TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2816
Mailing Address - Country:US
Mailing Address - Phone:510-652-4213
Mailing Address - Fax:510-652-1664
Practice Address - Street 1:444 34TH ST STE 4
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2816
Practice Address - Country:US
Practice Address - Phone:510-652-4213
Practice Address - Fax:510-652-1664
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19703106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist