Provider Demographics
NPI:1598878803
Name:FISH, MARK ALLAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:FISH
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 1:6333 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 506
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5721
Mailing Address - Country:US
Mailing Address - Phone:323-653-9092
Mailing Address - Fax:310-645-9531
Practice Address - Street 1:6333 WILSHIRE BLVD
Practice Address - Street 2:SUITE 506
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5721
Practice Address - Country:US
Practice Address - Phone:323-653-9092
Practice Address - Fax:310-645-9531
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical