Provider Demographics
NPI:1407069321
Name:BALDWIN, MARK (LPC-MHSP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 S ROYAL ST
Practice Address - Street 2:SUITE 24
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7307
Practice Address - Country:US
Practice Address - Phone:731-467-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1878101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506474Medicaid