Provider Demographics
NPI:1861662702
Name:GMOSER, MARK THOMAS
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:GMOSER
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:PO BOX 5306
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-5306
Mailing Address - Country:US
Mailing Address - Phone:818-821-0095
Mailing Address - Fax:
Practice Address - Street 1:7907 CHERRYSTONE AVE
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-6105
Practice Address - Country:US
Practice Address - Phone:188-210-0958
Practice Address - Fax:818-896-5069
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30893103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7420Medicaid
CA7068Medicaid