Provider Demographics
NPI:1114169711
Name:CHRISTIAN, MARK DONALD (LPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DONALD
Last Name:CHRISTIAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 FAIRFAX ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-5938
Mailing Address - Country:US
Mailing Address - Phone:920-233-1947
Mailing Address - Fax:
Practice Address - Street 1:1295 FAIRFAX ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-5938
Practice Address - Country:US
Practice Address - Phone:920-233-1947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1129-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional