Basic Information
| Provider Information | |||||||||
| NPI: | 1295869717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3580 WILSHIRE BLVD | ||||||||
| Address2: | STE. 800 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900102501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238760550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3580 WILSHIRE BLVD | ||||||||
| Address2: | STE. 800 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900102501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238760550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.