Basic Information
| Provider Information | |||||||||
| NPI: | 1356581698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOFFMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PRISON RD | ||||||||
| Address2: | CSP-SAC MENTAL HEALTH DEPT. | ||||||||
| City: | REPRESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956713000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169858610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 PRISON RD | ||||||||
| Address2: | CSP-SAC MENTAL HEALTH DEPT. | ||||||||
| City: | REPRESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956713000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169858610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2009 | ||||||||
| LastUpdateDate: | 02/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | PSY8428 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | Y | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TH0100X | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TR0400X | N | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
No ID Information.