Healthcare Provider Details

I. General information

NPI: 1346368040
Provider Name (Legal Business Name): MARK TIMOTHY MCDONALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 ELM AVE
LONG BEACH CA
90802-2426
US

IV. Provider business mailing address

633 E 1ST ST #12
LONG BEACH CA
90802-5102
US

V. Phone/Fax

Practice location:
  • Phone: 562-437-6717
  • Fax: 562-437-5072
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: