Provider Demographics
NPI:1609909399
Name:TAVITIAN, MARK L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:TAVITIAN
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 1:2730 S COUNTY TRL
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1730
Mailing Address - Country:US
Mailing Address - Phone:401-884-9895
Mailing Address - Fax:401-885-9898
Practice Address - Street 1:2730 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1730
Practice Address - Country:US
Practice Address - Phone:401-884-9895
Practice Address - Fax:401-885-9898
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI000358PS103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist