Provider Demographics
NPI:1982958153
Name:TANABE, MARK K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:K
Last Name:TANABE
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 1:23913 RANNEY HOUSE CT
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-3336
Mailing Address - Country:US
Mailing Address - Phone:626-278-2301
Mailing Address - Fax:
Practice Address - Street 1:595 E COLORADO BLVD STE 628
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-5222
Practice Address - Country:US
Practice Address - Phone:626-278-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01261511Medicaid