Provider Demographics
NPI:1841734423
Name:TRIBOULET, MARK WAYNE (LMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:TRIBOULET
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FESLER ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1968
Mailing Address - Country:US
Mailing Address - Phone:619-208-1696
Mailing Address - Fax:
Practice Address - Street 1:500 FESLER ST
Practice Address - Street 2:SUITE 208
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1968
Practice Address - Country:US
Practice Address - Phone:619-208-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96352106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist