Healthcare Provider Details

I. General information

NPI: 1457698359
Provider Name (Legal Business Name): MARVIN WADE ALTOM PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5014 CHESEBRO RD FL 2
AGOURA HILLS CA
91301-2278
US

IV. Provider business mailing address

13676 SHENANDOAH WAY
MOORPARK CA
93021-1262
US

V. Phone/Fax

Practice location:
  • Phone: 818-707-7366
  • Fax:
Mailing address:
  • Phone: 805-341-0084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 24619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: