Provider Demographics
NPI:1275808693
Name:GOBERT, MARK (ICCS, ICCJP, NCAC-II)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GOBERT
Suffix:
Gender:M
Credentials:ICCS, ICCJP, NCAC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-5006
Mailing Address - Country:US
Mailing Address - Phone:323-242-5000
Mailing Address - Fax:
Practice Address - Street 1:937 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93246-5006
Practice Address - Country:US
Practice Address - Phone:559-998-0718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)