Provider Demographics
NPI:1992899421
Name:PORTE, MICHAEL JOHN (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:PORTE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 FREMONT AVENUE
Mailing Address - Street 2:SUITE # 203
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3201
Mailing Address - Country:US
Mailing Address - Phone:626-403-4659
Mailing Address - Fax:626-403-4659
Practice Address - Street 1:1138 FREMONT AVENUE
Practice Address - Street 2:SUITE # 203
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3201
Practice Address - Country:US
Practice Address - Phone:626-403-4659
Practice Address - Fax:626-403-4659
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 117041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical