Provider Demographics
NPI:1942354337
Name:GERY, MARK R (MFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:GERY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 S DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-6012
Mailing Address - Country:US
Mailing Address - Phone:714-957-1647
Mailing Address - Fax:
Practice Address - Street 1:5122 KATELLA AVE
Practice Address - Street 2:201
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2826
Practice Address - Country:US
Practice Address - Phone:562-431-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32692106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist