Provider Demographics
NPI:1306255963
Name:MORTON, MARK RANDOLPH (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RANDOLPH
Last Name:MORTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 COMMERCENTER E
Mailing Address - Street 2:SUITE 232
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3456
Mailing Address - Country:US
Mailing Address - Phone:909-890-4466
Mailing Address - Fax:909-890-4278
Practice Address - Street 1:1881 COMMERCENTER E
Practice Address - Street 2:SUITE 232
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3456
Practice Address - Country:US
Practice Address - Phone:909-890-4466
Practice Address - Fax:909-890-4278
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80852106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist