Healthcare Provider Details

I. General information

NPI: 1568308260
Provider Name (Legal Business Name): THERESA LYNN MARK-MCKEEVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8903 VOULA LN
WILTON CA
95693-9628
US

IV. Provider business mailing address

PO BOX 905
WILTON CA
95693-0905
US

V. Phone/Fax

Practice location:
  • Phone: 916-838-4984
  • Fax:
Mailing address:
  • Phone: 916-838-4984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: