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General NPI Number Information
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NPI Number | 1003098427
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Entity Type | Individual
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Provider Name | MARK JOHN SOURIS PSYD
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Gender | Male
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Dates
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Enumeration Date | 11/27/2007
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Last Update Date | 11/17/2016
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Provider Practice Location Address
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Address Line | 21243 VENTURA BLVD SUITE 207
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City | WOODLAND HILLS
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State | CA
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Zip | 91364-2109
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Country | US
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Telephone | 818-635-9705
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Fax | 747-300-9246
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Provider Business Mailing Address
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Address Line | 19701 TUBA ST
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City | CHATSWORTH
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State | CA
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Zip | 91311-3547
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Country | US
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Telephone | 818-635-9705
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Fax | 747-300-9246
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY14283
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License Number State | CA
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