Provider Demographics
NPI:1215381918
Name:MARK JOHN SOURIS
Entity Type:Organization
Organization Name:MARK JOHN SOURIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SOURIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:818-635-9705
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:818-881-5504
Practice Address - Street 1:18757 BURBANK BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3375
Practice Address - Country:US
Practice Address - Phone:818-635-9705
Practice Address - Fax:818-881-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14283103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14283OtherLICENSE