Healthcare Provider Details

I. General information

NPI: 1982958153
Provider Name (Legal Business Name): MARK K TANABE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 E COLORADO BLVD STE 628
PASADENA CA
91101-5222
US

IV. Provider business mailing address

23913 RANNEY HOUSE CT
VALENCIA CA
91355-3336
US

V. Phone/Fax

Practice location:
  • Phone: 626-278-2301
  • Fax:
Mailing address:
  • Phone: 626-278-2301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY29456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: