Provider Demographics
NPI:1174545073
Name:ROSSDANSON, MARK H (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:ROSSDANSON
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 1:6310 SAN VICENTE BLVD STE 410
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5427
Mailing Address - Country:US
Mailing Address - Phone:323-932-1677
Mailing Address - Fax:
Practice Address - Street 1:6310 SAN VICENTE BLVD
Practice Address - Street 2:STE 410
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5457
Practice Address - Country:US
Practice Address - Phone:323-932-1677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12601103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12601Medicare ID - Type UnspecifiedPSYCHOLOGIST