=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184746505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK IMHOFF, PH.D., INC., A PSYCHOLOGICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2007
-----------------------------------------------------
Last Update Date | 12/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 W ALAMEDA AVE SUITE 110
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-843-8465
-----------------------------------------------------
Fax | 818-843-2435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 W ALAMEDA AVE SUITE 110
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-843-8465
-----------------------------------------------------
Fax | 818-843-2435
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MARK IMHOFF
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 818-843-8465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY7221
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------