Provider Demographics
NPI:1891723110
Name:MYERS, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MYERS
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 1:3350 LA JOLLA VILLAGE DR
Mailing Address - Street 2:VASDHS, 116B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0002
Mailing Address - Country:US
Mailing Address - Phone:858-642-3436
Mailing Address - Fax:858-552-7414
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:VASDHS, 116B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-642-3436
Practice Address - Fax:858-552-7414
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14945103T00000X
103TA0400X, 103TB0200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service