Basic Information
| Provider Information | |||||||||
| NPI: | 1346368040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 633 E 1ST ST | ||||||||
| Address2: | #12 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908025102 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 456 ELM AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908022426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624376717 | ||||||||
| FaxNumber: | 5624375072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 225C00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
No ID Information.