Healthcare Provider Details

I. General information

NPI: 1609967389
Provider Name (Legal Business Name): MARK RANDALL FLOYD PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MERTON MINTER ST PSYCHOLOGY SERVICE (116B)
SAN ANTONIO TX
78229-4404
US

IV. Provider business mailing address

7400 MERTON MINTER ST PSYCHOLOGY SERVICE (116B)
SAN ANTONIO TX
78229-4404
US

V. Phone/Fax

Practice location:
  • Phone: 210-617-5121
  • Fax: 210-949-3301
Mailing address:
  • Phone: 210-617-5121
  • Fax: 210-949-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 0397
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: