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General NPI Number Information
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NPI Number | 1457698359
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Entity Type | Individual
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Provider Name | MARVIN WADE ALTOM PH.D
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Gender | Male
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Dates
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Enumeration Date | 01/11/2013
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Last Update Date | 01/11/2013
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Provider Practice Location Address
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Address Line | 5014 CHESEBRO RD FL 2
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City | AGOURA HILLS
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State | CA
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Zip | 91301-2278
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Country | US
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Telephone | 818-707-7366
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Fax |
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Provider Business Mailing Address
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Address Line | 13676 SHENANDOAH WAY
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City | MOORPARK
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State | CA
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Zip | 93021-1262
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Country | US
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Telephone | 805-341-0084
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Fax |
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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 | PSY 24619
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License Number State | CA
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