Provider Demographics
NPI:1124043393
Name:KARZON, MARK ALLEN (LLMSW LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:KARZON
Suffix:
Gender:M
Credentials:LLMSW LCSW
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:ALLEN
Other - Last Name:KINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 200
Mailing Address - Street 2:
Mailing Address - City:FORT THOMPSON
Mailing Address - State:SD
Mailing Address - Zip Code:57339-0200
Mailing Address - Country:US
Mailing Address - Phone:605-245-1530
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 34 & 47
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339-0200
Practice Address - Country:US
Practice Address - Phone:605-245-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010874401041C0700X
IL1490128261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMK087440OtherBCBS OF MI
982471046799OtherPREFERRED ONE