Basic Information
| Provider Information | |||||||||
| NPI: | 1801138730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | DENEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRAZIER | ||||||||
| OtherFirstName: | REGINA | ||||||||
| OtherMiddleName: | DENEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 29748 RANCHO CALIFORNIA RD | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925915286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516940695 | ||||||||
| FaxNumber: | 9516956215 | ||||||||
| Practice Location | |||||||||
| Address1: | 29748 RANCHO CALIFORNIA RD | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925915286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516940695 | ||||||||
| FaxNumber: | 9516956215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2013 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF74148 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.