Provider Demographics
NPI:1154730885
Name:LINDHOLM, MARK RAY (MFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RAY
Last Name:LINDHOLM
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 E ATHERTON ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3700
Mailing Address - Country:US
Mailing Address - Phone:562-961-0155
Mailing Address - Fax:562-961-0161
Practice Address - Street 1:4525 E ATHERTON ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3700
Practice Address - Country:US
Practice Address - Phone:562-961-0155
Practice Address - Fax:562-961-0161
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9372106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist