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General NPI Number Information
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NPI Number | 1740534239
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Entity Type | Organization
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Legal Business Name | PORTA VERUM
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Dates
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Enumeration Date | 11/05/2012
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Last Update Date | 11/18/2013
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Provider Practice Location Address
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Address Line | 2630 1ST AVE SUITE 205
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City | SAN DIEGO
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State | CA
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Zip | 92103-6599
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Country | US
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Telephone | 619-866-4620
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Fax | 619-324-1023
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Provider Business Mailing Address
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Address Line | 2630 1ST AVE SUITE 205
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City | SAN DIEGO
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State | CA
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Zip | 92103-6599
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Country | US
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Telephone | 619-866-4620
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Fax | 619-324-1023
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Authorized Official
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Title or Position | OWNER
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Name | PAULA KETTULA
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Credential | LCSW
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Telephone | 619-866-4620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 25403
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License Number State | CA
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