Provider Demographics
NPI:1083930192
Name:DAGNALL, MARK (LMHC, LADC 1, CRC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DAGNALL
Suffix:
Gender:M
Credentials:LMHC, LADC 1, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 AMORY ST
Mailing Address - Street 2:REAR ENTRANCE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1051
Mailing Address - Country:US
Mailing Address - Phone:857-399-1915
Mailing Address - Fax:857-399-1901
Practice Address - Street 1:75 AMORY ST
Practice Address - Street 2:REAR ENTRANCE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-1051
Practice Address - Country:US
Practice Address - Phone:857-399-1915
Practice Address - Fax:857-399-1901
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2411101YA0400X
MA9039101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)