Provider Demographics
NPI:1245428697
Name:MARK, CONNIE JO (LCAS, LPC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JO
Last Name:MARK
Suffix:
Gender:F
Credentials:LCAS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 TIARA DR TRLR 3
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-7820
Mailing Address - Country:US
Mailing Address - Phone:704-730-8762
Mailing Address - Fax:
Practice Address - Street 1:133 TIARA DR TRLR 3
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-7820
Practice Address - Country:US
Practice Address - Phone:704-730-8762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6005931101YA0400X
NC6695101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)