Provider Demographics
NPI:1053012443
Name:VENNERHOLM, MARK EDWARD II (CMT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:VENNERHOLM
Suffix:II
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 B AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1998
Mailing Address - Country:US
Mailing Address - Phone:940-206-1838
Mailing Address - Fax:
Practice Address - Street 1:2305 S MELROSE DR STE 103
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8789
Practice Address - Country:US
Practice Address - Phone:760-230-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93040225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist