Healthcare Provider Details

I. General information

NPI: 1124793666
Provider Name (Legal Business Name): MARK J STERN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N GREGG AVE APT 4
FAYETTEVILLE AR
72703-2420
US

IV. Provider business mailing address

6977 NAVAJO RD # 432
SAN DIEGO CA
92119-1503
US

V. Phone/Fax

Practice location:
  • Phone: 619-894-6565
  • Fax:
Mailing address:
  • Phone: 619-250-2226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number202119
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY34309
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number202119
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number202119
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34309
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY34309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: