Provider Demographics
NPI:1205349255
Name:EBALO, MARK (PP-2)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:EBALO
Suffix:
Gender:M
Credentials:PP-2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 RIDDER PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2313
Mailing Address - Country:US
Mailing Address - Phone:669-205-2512
Mailing Address - Fax:
Practice Address - Street 1:1356 RIDDER PARK DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2313
Practice Address - Country:US
Practice Address - Phone:669-205-2512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker