Healthcare Provider Details

I. General information

NPI: 1609200385
Provider Name (Legal Business Name): MARK STEVEN BARAJAS PHD, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 SHATTUCK AVE STE 809
BERKELEY CA
94704-1229
US

IV. Provider business mailing address

1928 ST. MARY'S ROAD DEPARTMENT OF PSYCHOLOGY
MORAGA CA
94575-2744
US

V. Phone/Fax

Practice location:
  • Phone: 510-969-0758
  • Fax:
Mailing address:
  • Phone: 925-631-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301015413
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number30042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: