Provider Demographics
NPI:1417351727
Name:SOUTAR, MARK (LLP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SOUTAR
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:
Practice Address - Street 1:2881 MONROE ST
Practice Address - Street 2:SUITE #201
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3475
Practice Address - Country:US
Practice Address - Phone:313-359-1977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015605103TC0700X
MI6361003953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical