=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235316571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORLISS E. PORTER MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2008
-----------------------------------------------------
Last Update Date | 12/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 MARIN ST STE 202
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-4266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-702-5420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3503
-----------------------------------------------------
City | SANTA BARBARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93130-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-451-9419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT 11926
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------