Healthcare Provider Details

I. General information

NPI: 1518871185
Provider Name (Legal Business Name): MARK MCLAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 BRYDEN LN
SANTA ROSA CA
95404-3646
US

IV. Provider business mailing address

1537 LEONARD AVE
SANTA ROSA CA
95405-4520
US

V. Phone/Fax

Practice location:
  • Phone: 707-890-3950
  • Fax:
Mailing address:
  • Phone: 707-758-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP20528
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: