Basic Information
| Provider Information | |||||||||
| NPI: | 1790381671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | DARIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6333 TELEGRAPH AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109231099 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941031600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154873100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2020 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1790381671 | 05 | CA | MEDICAID | 0111 | 05 | CA | MEDICAID |