Provider Demographics
NPI:1235791542
Name:CONWAY, MARK CHARLES (LAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
Last Name:CONWAY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 W GREER AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-1104
Mailing Address - Country:US
Mailing Address - Phone:623-418-8407
Mailing Address - Fax:
Practice Address - Street 1:8466 W PEORIA AVE STE 6
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-6548
Practice Address - Country:US
Practice Address - Phone:602-497-3836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17511101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor