Basic Information
| Provider Information | |||||||||
| NPI: | 1124793666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STERN | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5821 BURNET AVE | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914113020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192502226 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2601 AIRPORT DR STE 135 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905056141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4242011600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2021 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | PSB94026059 | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.