Healthcare Provider Details

I. General information

NPI: 1265611024
Provider Name (Legal Business Name): MARIO DEWAYNE KIRK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 S TREMONT ST
OCEANSIDE CA
92054-5309
US

IV. Provider business mailing address

1738 S TREMONT ST
OCEANSIDE CA
92054-5309
US

V. Phone/Fax

Practice location:
  • Phone: 760-439-2800
  • Fax:
Mailing address:
  • Phone: 760-439-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3912
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3912
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number3912
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSB94023546
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: