Provider Demographics
NPI:1437267457
Name:ITZEN, MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ITZEN
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 1:6921 FRANKFORD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19135-1623
Mailing Address - Country:US
Mailing Address - Phone:215-332-3240
Mailing Address - Fax:215-332-3241
Practice Address - Street 1:6921 FRANKFORD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-1623
Practice Address - Country:US
Practice Address - Phone:215-332-3240
Practice Address - Fax:215-332-3241
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0141251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical