Provider Demographics
NPI:1164525580
Name:VELLUCCI, MARK ANTHONY (MA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:VELLUCCI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11818 SE MILL PLAIN BLVD STE 311C
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5091
Mailing Address - Country:US
Mailing Address - Phone:360-571-3981
Mailing Address - Fax:503-578-2454
Practice Address - Street 1:11818 SE MILL PLAIN BLVD
Practice Address - Street 2:SUITE 311C
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:99684
Practice Address - Country:US
Practice Address - Phone:360-571-3981
Practice Address - Fax:503-578-2454
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004640101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health