=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255486270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK RICHARD ZASLAV PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 TAMAL VISTA BLVD STE 120
-----------------------------------------------------
City | CORTE MADERA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94925-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-927-1560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 GLEN WAY
-----------------------------------------------------
City | LARKSPUR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94939-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-927-1560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | PSY 9205
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 9205
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number | PSY 9205
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------