Provider Demographics
NPI:1356457642
Name:COLTERJOHN, MARK W (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:COLTERJOHN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PARK TER E
Mailing Address - Street 2:APT 6G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1513
Mailing Address - Country:US
Mailing Address - Phone:646-872-5451
Mailing Address - Fax:
Practice Address - Street 1:920 BROADWAY
Practice Address - Street 2:8TH FLOOR, SUITE #2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6004
Practice Address - Country:US
Practice Address - Phone:646-872-5451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2010-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0702391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN63C01Medicare ID - Type Unspecified