Provider Demographics
NPI:1922042886
Name:ALLEN, MARK HUGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:HUGH
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4153 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2047
Mailing Address - Country:US
Mailing Address - Phone:619-685-2736
Mailing Address - Fax:619-298-7267
Practice Address - Street 1:4153 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2047
Practice Address - Country:US
Practice Address - Phone:619-685-2736
Practice Address - Fax:619-298-7267
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11665103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY116650Medicaid
CAPSY116650Medicaid