Provider Demographics
NPI:1477276202
Name:HART, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HART
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:PO BOX 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:601-705-1901
Practice Address - Street 1:211 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-4503
Practice Address - Country:US
Practice Address - Phone:601-798-7001
Practice Address - Fax:601-799-4481
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3487101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor