Provider Demographics
NPI:1558748665
Name:MARK, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARK
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 1:1230 ROSECRANS AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2477
Mailing Address - Country:US
Mailing Address - Phone:424-456-3020
Mailing Address - Fax:424-456-3021
Practice Address - Street 1:1230 ROSECRANS AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2477
Practice Address - Country:US
Practice Address - Phone:424-456-3020
Practice Address - Fax:424-456-3021
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-47-90333OtherFRANCHISE TAX BOARD