Provider Demographics
NPI:1457698359
Name:ALTOM, MARVIN WADE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:WADE
Last Name:ALTOM
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 1:13676 SHENANDOAH WAY
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1262
Mailing Address - Country:US
Mailing Address - Phone:805-341-0084
Mailing Address - Fax:
Practice Address - Street 1:5014 CHESEBRO RD FL 2
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2278
Practice Address - Country:US
Practice Address - Phone:818-707-7366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24619103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical