Provider Demographics
NPI:1053628321
Name:HEYNE, MARK MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MICHAEL
Last Name:HEYNE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 F AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1231
Mailing Address - Country:US
Mailing Address - Phone:773-383-0068
Mailing Address - Fax:
Practice Address - Street 1:140 SYLVESTER RD
Practice Address - Street 2:BUILDING 500
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-3521
Practice Address - Country:US
Practice Address - Phone:619-553-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25610103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical