Healthcare Provider Details

I. General information

NPI: 1598337529
Provider Name (Legal Business Name): MARK FREEMAN PPS SP, PPS SCG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 W AVENUE 40
LOS ANGELES CA
90065-3631
US

IV. Provider business mailing address

3751 W AVENUE 40
LOS ANGELES CA
90065-3631
US

V. Phone/Fax

Practice location:
  • Phone: 818-648-6777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number170047142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: