Provider Demographics
NPI:1700460904
Name:PORTER, MCDONALD ELLIOT
Entity type:Individual
Prefix:
First Name:MCDONALD
Middle Name:ELLIOT
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MAC
Other - Middle Name:ELLIOT
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:859 47TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-3258
Mailing Address - Country:US
Mailing Address - Phone:201-954-1659
Mailing Address - Fax:
Practice Address - Street 1:2325 CLEMENT AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-7063
Practice Address - Country:US
Practice Address - Phone:510-629-6309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program