Provider Demographics
NPI:1144751348
Name:KROLL, MARK DURHAM (LSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DURHAM
Last Name:KROLL
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 KESTRAL BLVD APT D
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-6702
Mailing Address - Country:US
Mailing Address - Phone:765-543-0478
Mailing Address - Fax:866-406-5077
Practice Address - Street 1:2435 KESTRAL BLVD APT D
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-6702
Practice Address - Country:US
Practice Address - Phone:765-543-0478
Practice Address - Fax:866-406-5077
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3300570A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)