Provider Demographics
NPI:1083817001
Name:PAUL, MARK (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PAUL
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-3968
Mailing Address - Country:US
Mailing Address - Phone:413-540-1155
Mailing Address - Fax:
Practice Address - Street 1:319 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3968
Practice Address - Country:US
Practice Address - Phone:413-540-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1027531101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307819Medicaid
MA1307819Medicare UPIN
MAY10324Medicare ID - Type Unspecified