Healthcare Provider Details

I. General information

NPI: 1558109942
Provider Name (Legal Business Name): MARK ZUCKERBROW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 GOUGH ST STE 401
SAN FRANCISCO CA
94102-5971
US

IV. Provider business mailing address

472 38TH ST APT B
OAKLAND CA
94609-2729
US

V. Phone/Fax

Practice location:
  • Phone: 415-212-6478
  • Fax:
Mailing address:
  • Phone: 917-561-6862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number159474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: