Provider Demographics
NPI:1033190236
Name:HAWRYLO, MARK JOHN II (LISW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOHN
Last Name:HAWRYLO
Suffix:II
Gender:M
Credentials:LISW
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:JOHN
Other - Last Name:HAWRYLO
Other - Suffix:II
Other - Last Name Type:Former Name
Other - Credentials:MSW, LISW-S
Mailing Address - Street 1:7519 MENTOR AVE
Mailing Address - Street 2:SUITE - A- 110
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5434
Mailing Address - Country:US
Mailing Address - Phone:440-521-4673
Mailing Address - Fax:440-521-4673
Practice Address - Street 1:7519 MENTOR AVE
Practice Address - Street 2:SUITE - A- 110
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5434
Practice Address - Country:US
Practice Address - Phone:440-521-4673
Practice Address - Fax:440-521-4673
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI9073104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHHASW25771Medicare ID - Type Unspecified
OHHASW- 25771Medicare UPIN