Provider Demographics
NPI:1124793666
Name:STERN, MARK J (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:STERN
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6977 NAVAJO RD # 432
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1503
Mailing Address - Country:US
Mailing Address - Phone:619-250-2226
Mailing Address - Fax:
Practice Address - Street 1:1800 N GREGG AVE APT 4
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2420
Practice Address - Country:US
Practice Address - Phone:619-894-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR202119103G00000X, 103TC0700X, 103TH0004X
CAPSY34309103G00000X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth