Provider Demographics
NPI:1538834072
Name:WORRELL, MARK WILLIAM
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:WORRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13643 HATTERAS ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4519
Mailing Address - Country:US
Mailing Address - Phone:818-997-7635
Mailing Address - Fax:
Practice Address - Street 1:13643 HATTERAS ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-4519
Practice Address - Country:US
Practice Address - Phone:818-997-7635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10897225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty