Provider Demographics
NPI:1225196454
Name:FIELDSON, MARK (MFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:FIELDSON
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 1:12875 MARTHA ANN DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-4923
Mailing Address - Country:US
Mailing Address - Phone:562-754-3005
Mailing Address - Fax:562-598-5997
Practice Address - Street 1:4132 KATELLA AVE
Practice Address - Street 2:104
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3426
Practice Address - Country:US
Practice Address - Phone:562-754-3005
Practice Address - Fax:562-598-5997
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25467106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist