Provider Demographics
NPI:1356331110
Name:APPLEWHITE, MARK VERNON (NY STATE LCSW-R)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:VERNON
Last Name:APPLEWHITE
Suffix:
Gender:M
Credentials:NY STATE LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E MAIN ST UNIT 482
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-6022
Mailing Address - Country:US
Mailing Address - Phone:631-948-5383
Mailing Address - Fax:
Practice Address - Street 1:58 HENRY ST
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754
Practice Address - Country:US
Practice Address - Phone:631-948-5383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2019-10-31
Deactivation Date:2019-10-22
Deactivation Code:
Reactivation Date:2019-10-31
Provider Licenses
StateLicense IDTaxonomies
NY0727691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN527A1Medicare ID - Type Unspecified