Healthcare Provider Details

I. General information

NPI: 1457561540
Provider Name (Legal Business Name): MATTHEW DARREN PORTER MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 16TH AVE
SAN FRANCISCO CA
94118-2812
US

IV. Provider business mailing address

1818 11TH AVE
SAN FRANCISCO CA
94122-4604
US

V. Phone/Fax

Practice location:
  • Phone: 415-505-2787
  • Fax:
Mailing address:
  • Phone: 415-505-2787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 42042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: