Provider Demographics
NPI:1346402765
Name:LENZENWEGER, MARK FRANCIS (PHD)
Entity Type:Individual
Prefix:PROF
First Name:MARK
Middle Name:FRANCIS
Last Name:LENZENWEGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 UTICA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3640
Mailing Address - Country:US
Mailing Address - Phone:607-777-7148
Mailing Address - Fax:607-777-4890
Practice Address - Street 1:122A WEST BUFFALO ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-777-7148
Practice Address - Fax:607-777-4890
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009577103TC0700X
MA7378103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical