Healthcare Provider Details

I. General information

NPI: 1225507650
Provider Name (Legal Business Name): MARK LAWRENCE MOTOL SY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N CARMELO AVE
PASADENA CA
91107-2500
US

IV. Provider business mailing address

411 N CARMELO AVE
PASADENA CA
91107-2500
US

V. Phone/Fax

Practice location:
  • Phone: 626-484-2538
  • Fax:
Mailing address:
  • Phone: 213-383-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95085268
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: