Provider Demographics
NPI:1619690401
Name:LIFEMARK MARRIAGE & FAMILY THERAPY CORPORATION
Entity Type:Organization
Organization Name:LIFEMARK MARRIAGE & FAMILY THERAPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:EVOSEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:760-413-1951
Mailing Address - Street 1:3819 1ST AVE UNIT 208
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3082
Mailing Address - Country:US
Mailing Address - Phone:760-413-1951
Mailing Address - Fax:
Practice Address - Street 1:3819 1ST AVE UNIT 208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3082
Practice Address - Country:US
Practice Address - Phone:760-413-1951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty