=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841625753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK REID
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2013
-----------------------------------------------------
Last Update Date | 01/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 E COLORADO BLVD STE 807
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-6106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-737-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 SIERRA VIEW RD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-1450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-390-0966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | IMF64851
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------