Provider Demographics
NPI:1003098427
Name:SOURIS, MARK JOHN (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:SOURIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:19701 TUBA ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-3547
Mailing Address - Country:US
Mailing Address - Phone:818-635-9705
Mailing Address - Fax:747-300-9246
Practice Address - Street 1:21243 VENTURA BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2109
Practice Address - Country:US
Practice Address - Phone:818-635-9705
Practice Address - Fax:747-300-9246
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY14283103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14283OtherLICENSE NUMBER