Provider Demographics
NPI:1962693762
Name:PORTER, GINA-MARIE CIMMARRUSTI (MFTI, AT)
Entity type:Individual
Prefix:
First Name:GINA-MARIE
Middle Name:CIMMARRUSTI
Last Name:PORTER
Suffix:
Gender:F
Credentials:MFTI, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22985 DITZ LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4112
Mailing Address - Country:US
Mailing Address - Phone:949-701-0598
Mailing Address - Fax:
Practice Address - Street 1:22985 DITZ LN
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4112
Practice Address - Country:US
Practice Address - Phone:949-701-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 57337106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist