Provider Demographics
NPI:1043619992
Name:MARK S. DEBORD, LCSW, LLC
Entity Type:Organization
Organization Name:MARK S. DEBORD, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEBORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:318-381-9070
Mailing Address - Street 1:212 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-3120
Mailing Address - Country:US
Mailing Address - Phone:318-381-9070
Mailing Address - Fax:318-322-1477
Practice Address - Street 1:212 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-3120
Practice Address - Country:US
Practice Address - Phone:318-381-9070
Practice Address - Fax:318-322-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1947261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)