Provider Demographics
NPI:1376189431
Name:LAFOND, MARK DAVID
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:LAFOND
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 1:2109 FAIRBURN RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1037
Mailing Address - Country:US
Mailing Address - Phone:770-726-7958
Mailing Address - Fax:
Practice Address - Street 1:2109 FAIRBURN RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1037
Practice Address - Country:US
Practice Address - Phone:770-726-7958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054516517OtherDRIVERS LICENSE