Provider Demographics
NPI:1871785782
Name:MARK, DONNA REVAE
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:REVAE
Last Name:MARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3740
Mailing Address - Country:US
Mailing Address - Phone:310-984-3055
Mailing Address - Fax:310-984-3066
Practice Address - Street 1:921 S BEACON ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3740
Practice Address - Country:US
Practice Address - Phone:310-984-3055
Practice Address - Fax:310-984-3066
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55577OtherBOARD OF BEHAVIORAL SERVICES