Provider Demographics
NPI:1023377876
Name:THEUERKAUF, MARK (MS NCC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:THEUERKAUF
Suffix:
Gender:M
Credentials:MS NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-1250
Mailing Address - Country:US
Mailing Address - Phone:814-323-1891
Mailing Address - Fax:
Practice Address - Street 1:816 POPLAR ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-1250
Practice Address - Country:US
Practice Address - Phone:814-323-1891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA292308101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor