MEDICARE: MR. MARK FIELDSON M.F.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC25467	CA

General Provider Information

NPI Number	:	1225196454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK FIELDSON M.F.T.

Provider Business Mailing Address
First Line	:	12875 MARTHA ANN DR
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-4923
Country	:	US
Telephone Number	:	562-754-3005
Fax Number	:	562-598-5997

Provider Business Practice Location Address
First Line	:	4132 KATELLA AVE
Second Line	:	104
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3426
Country	:	US
Telephone Number	:	562-754-3005
Fax Number	:	562-598-5997

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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