Provider Demographics
NPI:1285117176
Name:STEIN, MARK WILLIAM (MA, AMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:STEIN
Suffix:
Gender:M
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5413
Mailing Address - Country:US
Mailing Address - Phone:323-445-0931
Mailing Address - Fax:
Practice Address - Street 1:1626 WESTWOOD BLVD STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5621
Practice Address - Country:US
Practice Address - Phone:323-445-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101912106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist