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General NPI Number Information
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NPI Number | 1215381918
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Entity Type | Organization
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Legal Business Name | MARK JOHN SOURIS
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Dates
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Enumeration Date | 04/19/2016
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Last Update Date | 04/19/2016
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Provider Practice Location Address
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Address Line | 18757 BURBANK BLVD SUITE 125
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City | TARZANA
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State | CA
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Zip | 91356-3375
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Country | US
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Telephone | 818-635-9705
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Fax | 818-881-5504
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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 | 818-881-5504
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK JOHN SOURIS
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Credential | PSYD
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Telephone | 818-635-9705
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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 | 14283
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License Number State | CA
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