Basic Information
| Provider Information | |||||||||
| NPI: | 1043528383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | PORSCHE | ||||||||
| MiddleName: | MONIC | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TERRY | ||||||||
| OtherFirstName: | PORSCHE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ASW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2008 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2008 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2010 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW28940 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.