Provider Demographics
NPI:1104177500
Name:MAGIN, MARK ANTHONY (OTR, QMHP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:MAGIN
Suffix:
Gender:M
Credentials:OTR, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 S BURDICK ST
Mailing Address - Street 2:STE. 200
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-6219
Mailing Address - Country:US
Mailing Address - Phone:269-381-4446
Mailing Address - Fax:269-381-4457
Practice Address - Street 1:414 S BURDICK ST
Practice Address - Street 2:STE. 200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-6219
Practice Address - Country:US
Practice Address - Phone:269-381-4446
Practice Address - Fax:269-381-4457
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004848171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator