Provider Demographics
NPI:1063442747
Name:ROY, MARK ALLEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:ROY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ESSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2841
Mailing Address - Country:US
Mailing Address - Phone:815-725-2272
Mailing Address - Fax:
Practice Address - Street 1:1000 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-2841
Practice Address - Country:US
Practice Address - Phone:708-535-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL917650Medicare ID - Type Unspecified