Provider Demographics
NPI:1073663555
Name:PROHASKA, MARK LINDEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LINDEN
Last Name:PROHASKA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 RICE MINE ROAD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406
Mailing Address - Country:US
Mailing Address - Phone:205-344-6169
Mailing Address - Fax:205-344-6171
Practice Address - Street 1:100 RICE MINE ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406
Practice Address - Country:US
Practice Address - Phone:205-344-6169
Practice Address - Fax:205-344-6171
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL816103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51504930OtherBLUE CROSS
ALS27539Medicare UPIN
AL051550971Medicare PIN