Provider Demographics
NPI:1073736484
Name:OLTHOFF, MARK WARREN (MSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WARREN
Last Name:OLTHOFF
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10075 NORTHLAND DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8067
Mailing Address - Country:US
Mailing Address - Phone:616-866-0265
Mailing Address - Fax:616-866-0991
Practice Address - Street 1:10075 NORTHLAND DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-8067
Practice Address - Country:US
Practice Address - Phone:616-866-0265
Practice Address - Fax:616-866-0991
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010356151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical