Provider Demographics
NPI:1083722276
Name:KANE, MARK S (PHD CSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:KANE
Suffix:
Gender:M
Credentials:PHD CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 PARCHMENT DRIVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-464-0811
Mailing Address - Fax:616-464-0812
Practice Address - Street 1:1015 PARCHMENT DRIVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-464-0811
Practice Address - Fax:616-464-0812
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009094103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N82850001Medicare ID - Type Unspecified