Provider Demographics
NPI:1245551837
Name:NEWMARK, MICHAEL (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NEWMARK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 4TH ST STE G
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4345
Mailing Address - Country:US
Mailing Address - Phone:707-327-7113
Mailing Address - Fax:844-512-6979
Practice Address - Street 1:1049 4TH ST STE G
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4345
Practice Address - Country:US
Practice Address - Phone:707-327-7113
Practice Address - Fax:844-512-6979
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28208103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist