Healthcare Provider Details

I. General information

NPI: 1154730885
Provider Name (Legal Business Name): MARK RAY LINDHOLM MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 E ATHERTON ST
LONG BEACH CA
90815-3700
US

IV. Provider business mailing address

4525 E ATHERTON ST
LONG BEACH CA
90815-3700
US

V. Phone/Fax

Practice location:
  • Phone: 562-961-0155
  • Fax: 562-961-0161
Mailing address:
  • Phone: 562-961-0155
  • Fax: 562-961-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number9372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: