Provider Demographics
NPI:1932122934
Name:SUMMERSON, MARK THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:SUMMERSON
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 1:254 E MAIN ST
Mailing Address - Street 2:SUITE 226
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-2678
Mailing Address - Country:US
Mailing Address - Phone:509-330-5456
Mailing Address - Fax:509-561-6229
Practice Address - Street 1:254 E MAIN ST
Practice Address - Street 2:SUITE 226
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-2678
Practice Address - Country:US
Practice Address - Phone:509-330-5456
Practice Address - Fax:509-561-6229
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA2258103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S98972Medicare UPIN
WAAB13706Medicare ID - Type Unspecified