Provider Demographics
NPI:1114145612
Name:FOSSIE, MARK STEVEN (MS, LMFT, CSAC, ICS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVEN
Last Name:FOSSIE
Suffix:
Gender:M
Credentials:MS, LMFT, CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 N 4TH ST
Mailing Address - Street 2:516
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2362
Mailing Address - Country:US
Mailing Address - Phone:414-263-6000
Mailing Address - Fax:414-263-2270
Practice Address - Street 1:2821 N 4TH ST
Practice Address - Street 2:516
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2362
Practice Address - Country:US
Practice Address - Phone:414-263-6000
Practice Address - Fax:414-263-2270
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14971-132101YA0400X
WI402104100000X
WI460-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist