Provider Demographics
NPI:1306338892
Name:FROMM, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FROMM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3296 JORDAN RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-3535
Mailing Address - Country:US
Mailing Address - Phone:510-220-2183
Mailing Address - Fax:
Practice Address - Street 1:3296 JORDAN RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-3535
Practice Address - Country:US
Practice Address - Phone:510-220-2183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9258103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist