Provider Demographics
NPI:1962458661
Name:SOLOMON, MARK JACOB (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JACOB
Last Name:SOLOMON
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 1:1808 WOODBURN RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-5725
Mailing Address - Country:US
Mailing Address - Phone:919-225-5916
Mailing Address - Fax:
Practice Address - Street 1:110 E QUEEN ST
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2138
Practice Address - Country:US
Practice Address - Phone:919-225-5916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2585103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical