Healthcare Provider Details

I. General information

NPI: 1154319069
Provider Name (Legal Business Name): MARK L PARIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12584 DARBY BROOK CT
WOODBRIDGE VA
22192-2485
US

IV. Provider business mailing address

8028 OAK HOLLOW LN
FAIRFAX STATION VA
22039-2627
US

V. Phone/Fax

Practice location:
  • Phone: 793-431-3940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005324
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: