Provider Demographics
NPI:1477100279
Name:PHELAN, MARK DENNIS (LMFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DENNIS
Last Name:PHELAN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 20TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5635
Mailing Address - Country:US
Mailing Address - Phone:310-699-4187
Mailing Address - Fax:
Practice Address - Street 1:1118 20TH ST APT B
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5635
Practice Address - Country:US
Practice Address - Phone:310-699-4187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115079106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist