Healthcare Provider Details

I. General information

NPI: 1487445649
Provider Name (Legal Business Name): MARK WYSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26659 WHITEHORN DR
RANCHO PALOS VERDES CA
90275-2352
US

IV. Provider business mailing address

26659 WHITEHORN DR
RANCHO PALOS VERDES CA
90275-2352
US

V. Phone/Fax

Practice location:
  • Phone: 310-897-4922
  • Fax:
Mailing address:
  • Phone: 310-897-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number130661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: