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General NPI Number Information
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NPI Number | 1184974073
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Entity Type | Individual
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Provider Name | JONATHAN GAVIN PORTO LMFT 150139
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Gender | Male
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Dates
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Enumeration Date | 09/18/2012
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Last Update Date | 01/21/2025
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Provider Practice Location Address
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Address Line | 1400 E JANSS RD
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City | THOUSAND OAKS
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State | CA
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Zip | 91362-2133
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Country | US
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Telephone | 805-497-9511
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Fax |
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Provider Business Mailing Address
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Address Line | 567 W CHANNEL ISLANDS BLVD # 166
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City | PORT HUENEME
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State | CA
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Zip | 93041-2133
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Country | US
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Telephone | 805-512-6764
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 150139
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License Number State | CA
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