Provider Demographics
NPI:1720823339
Name:MARKS, TAMARA LEE
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:LEE
Last Name:MARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 NASSAU DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-7140
Mailing Address - Country:US
Mailing Address - Phone:904-612-9112
Mailing Address - Fax:
Practice Address - Street 1:8058 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0335
Practice Address - Country:US
Practice Address - Phone:904-612-9112
Practice Address - Fax:619-782-0857
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94027510103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist