Provider Demographics
NPI:1386381275
Name:WIGHT, MARK (AMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WIGHT
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35503 CRABAPPLE ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4594
Mailing Address - Country:US
Mailing Address - Phone:951-440-0269
Mailing Address - Fax:
Practice Address - Street 1:7899 MISSION GROVE PKWY S STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-5062
Practice Address - Country:US
Practice Address - Phone:951-776-9223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CAAMFT150705106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
34348987OtherRBT
CA1386381275OtherAMFT