Provider Demographics
NPI:1316204910
Name:MARK L. TAVITIAN, PH.D., LTD.
Entity type:Organization
Organization Name:MARK L. TAVITIAN, PH.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAVITIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:401-884-9895
Mailing Address - Street 1:2730 S COUNTY TRL
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1730
Mailing Address - Country:US
Mailing Address - Phone:401-884-9895
Mailing Address - Fax:401-885-9898
Practice Address - Street 1:2730 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1730
Practice Address - Country:US
Practice Address - Phone:401-884-9895
Practice Address - Fax:401-885-9898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS358103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty