Provider Demographics
NPI:1770617789
Name:EMMITT, MARK (MFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:EMMITT
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 1:29141 OAKPATH DR
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-1677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:818-441-0014
Practice Address - Street 1:3625 E THOUSAND OAKS BLVD
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-3626
Practice Address - Country:US
Practice Address - Phone:818-857-7175
Practice Address - Fax:818-441-0014
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40444106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASYC1018OtherMEDICAL