Basic Information
| Provider Information | |||||||||
| NPI: | 1275808693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOBERT | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | ICCS, ICCJP, NCAC-II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11601 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900475006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232425000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 937 FRANKLIN BLVD | ||||||||
| Address2: | |||||||||
| City: | LEMOORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932465006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599980718 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2012 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.