MEDICARE: ANGELA GABRIEL PORTER MA, RAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1578904801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA GABRIEL PORTER MA, RAS

Provider Business Mailing Address
First Line	:	2323 HEARST AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94709-1319
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 SCENIC AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94709-1324
Country	:	US
Telephone Number	:	510-548-7270
Fax Number	:	510-665-3176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2013
Last Update Date	:	07/15/2013

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