Provider Demographics
NPI:1225507650
Name:SY, MARK LAWRENCE MOTOL
Entity Type:Individual
Prefix:
First Name:MARK LAWRENCE
Middle Name:MOTOL
Last Name:SY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N CARMELO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2500
Mailing Address - Country:US
Mailing Address - Phone:213-383-0050
Mailing Address - Fax:
Practice Address - Street 1:411 N CARMELO AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-2500
Practice Address - Country:US
Practice Address - Phone:626-484-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95085268163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health