Provider Demographics
NPI:1326436999
Name:MARK, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 TRYSTING PL
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1348
Mailing Address - Country:US
Mailing Address - Phone:516-241-1177
Mailing Address - Fax:
Practice Address - Street 1:579 TRYSTING PL
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1348
Practice Address - Country:US
Practice Address - Phone:516-241-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084806104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker