Provider Demographics
NPI:1558789701
Name:GARCIA, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GARCIA
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 1:2620 CENTENARY BLVD
Mailing Address - Street 2:BLDG. #3, SUITE 207
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3356
Mailing Address - Country:US
Mailing Address - Phone:318-676-7650
Mailing Address - Fax:
Practice Address - Street 1:2620 CENTENARY BLVD
Practice Address - Street 2:BLDG. #3, SUITE 207
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3356
Practice Address - Country:US
Practice Address - Phone:318-676-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1098103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1098OtherLIC TO PRACTICE PSYCHOLOGY