Provider Demographics
NPI:1457440216
Name:LANNON, MARK R (LCSW-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:LANNON
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12738 LITTLE ANTIETAM RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-4942
Mailing Address - Country:US
Mailing Address - Phone:301-791-6240
Mailing Address - Fax:
Practice Address - Street 1:1180 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5852
Practice Address - Country:US
Practice Address - Phone:301-791-3045
Practice Address - Fax:240-313-3071
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD036861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKL41F841Medicare ID - Type UnspecifiedPROVIDER # GROUP