| Doctor Name: | MARK JOHN SOURIS |
| NPI Number: | 1003098427 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | PSY14283 |
| Business Practice Address: | 18757 Burbank Blvd Suite 125 Tarzana, CA - 913563375 |
| Business Phone Number: | 8186359705 |
| Business Fax Number: | 8188815504 |
| Mailing Address: | 19701 Tuba St, CHATSWORTH |
| State: | CA |
| Postal Code: | 913113547 |
| Phone Number: | 8186359705 |
| Fax Number: | 8188815504 |
| NPI Enumeration Date: | 11/27/2007 |
| NPI Last Update Date: | 04/19/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | PSY14283 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |