Provider Demographics
NPI:1508305616
Name:FLORENTINO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FLORENTINO
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 1:100 GEORGE P HASSETT DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3258
Mailing Address - Country:US
Mailing Address - Phone:781-393-4828
Mailing Address - Fax:
Practice Address - Street 1:100 GEORGE P HASSETT DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3258
Practice Address - Country:US
Practice Address - Phone:781-393-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor