Provider Demographics
NPI:1316204399
Name:NEVILL, MARK A (DED)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:NEVILL
Suffix:
Gender:M
Credentials:DED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3609
Mailing Address - Street 2:2400 REACH ROAD
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-8609
Mailing Address - Country:US
Mailing Address - Phone:570-323-8561
Mailing Address - Fax:570-323-1738
Practice Address - Street 1:2400 REACH RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-4381
Practice Address - Country:US
Practice Address - Phone:570-323-8561
Practice Address - Fax:570-323-1738
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017129103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool