Provider Demographics
NPI:1063687481
Name:SPURLOCK, MARK ALLEN (MFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:SPURLOCK
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 218
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1571
Mailing Address - Country:US
Mailing Address - Phone:619-813-0315
Mailing Address - Fax:
Practice Address - Street 1:4540 KEARNY VILLA RD
Practice Address - Street 2:SUITE 218
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1571
Practice Address - Country:US
Practice Address - Phone:619-813-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-26
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 45318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist