Provider Demographics
NPI:1598528705
Name:MARK, ILANA
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 N 37TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2242
Mailing Address - Country:US
Mailing Address - Phone:954-483-4834
Mailing Address - Fax:
Practice Address - Street 1:5001 N 37TH ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2242
Practice Address - Country:US
Practice Address - Phone:954-483-4834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5921103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical