Provider Demographics
NPI:1649549163
Name:LANDEROS, MARK
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:LANDEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E ARROW HWY
Mailing Address - Street 2:102
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3364
Mailing Address - Country:US
Mailing Address - Phone:909-293-7850
Mailing Address - Fax:
Practice Address - Street 1:301 E ARROW HWY
Practice Address - Street 2:102
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3364
Practice Address - Country:US
Practice Address - Phone:909-293-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor