Provider Demographics
NPI:1336498724
Name:PIERCE, MARK DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:PIERCE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 W. OLIVE AVENUE, PMB250
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506
Mailing Address - Country:US
Mailing Address - Phone:818-563-6550
Mailing Address - Fax:
Practice Address - Street 1:2219 WEST OLIVE AVENUE, #250
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2648
Practice Address - Country:US
Practice Address - Phone:818-563-6550
Practice Address - Fax:818-563-3420
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12404103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic