Provider Demographics
NPI:1891898391
Name:VERDUGO, MARK STEVEN (CCPS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVEN
Last Name:VERDUGO
Suffix:
Gender:M
Credentials:CCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 GRANITE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-3330
Mailing Address - Country:US
Mailing Address - Phone:562-397-8401
Mailing Address - Fax:
Practice Address - Street 1:351 WILKERSON AVE STE D
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2203
Practice Address - Country:US
Practice Address - Phone:562-397-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPS04602101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)