Provider Demographics
NPI:1679716070
Name:MARK, DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 ANTHWYN RD
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-2302
Mailing Address - Country:US
Mailing Address - Phone:610-664-5302
Mailing Address - Fax:215-349-5171
Practice Address - Street 1:408 ANTHWYN RD
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-2302
Practice Address - Country:US
Practice Address - Phone:610-664-5302
Practice Address - Fax:215-349-5171
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-004947-L102L00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst