Provider Demographics
NPI:1659791358
Name:TAWFIK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TAWFIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3740
Mailing Address - Country:US
Mailing Address - Phone:310-984-3055
Mailing Address - Fax:
Practice Address - Street 1:921 S BEACON ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3740
Practice Address - Country:US
Practice Address - Phone:310-984-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79474101YM0800X
CA79474106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDI-CAL
CA7667OtherMEDI-CAL
CA7184OtherMEDI-CAL
CA7368OtherMEDI-CAL