Healthcare Provider Details

I. General information

NPI: 1992358956
Provider Name (Legal Business Name): REBECCA MIRIAM PORTNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA M PORTNER LCSW

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S LONG BEACH BLVD
COMPTON CA
90221-3423
US

IV. Provider business mailing address

10937 ANGELL ST
NORWALK CA
90650-2535
US

V. Phone/Fax

Practice location:
  • Phone: 310-627-5850
  • Fax:
Mailing address:
  • Phone: 818-429-7926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: