Provider Demographics
NPI:1790828671
Name:LOVELADY, MARK THOMAS
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
Last Name:LOVELADY
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 1:1664 MAPLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3929
Mailing Address - Country:US
Mailing Address - Phone:626-433-1311
Mailing Address - Fax:626-433-1313
Practice Address - Street 1:1664 MAPLEWOOD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3929
Practice Address - Country:US
Practice Address - Phone:626-433-1311
Practice Address - Fax:626-433-1313
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33201167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician