Provider Demographics
NPI:1891916698
Name:CAPITOLO, MARK DAVID (MFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:CAPITOLO
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:MR
Other - First Name:UNKNOWN
Other - Middle Name:DAVID
Other - Last Name:CAPITOLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:1480 LINCOLN AVE
Mailing Address - Street 2:#10
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-456-5596
Mailing Address - Fax:415-479-7144
Practice Address - Street 1:1480 LINCOLN AVE
Practice Address - Street 2:#10
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:415-456-5596
Practice Address - Fax:415-479-7144
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MFT35458106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist