=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053628321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK MICHAEL HEYNE PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2010
-----------------------------------------------------
Last Update Date | 04/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 SYLVESTER RD BUILDING 500
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92106-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-553-8555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 F AVE
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-383-0068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 25610
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------