Provider Demographics
NPI:1508884370
Name:KRIST, MARK J (LMSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:KRIST
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 CORRIDA DE AGUA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2885
Mailing Address - Country:US
Mailing Address - Phone:906-458-6979
Mailing Address - Fax:
Practice Address - Street 1:2960 RODEO PARK DR W
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6351
Practice Address - Country:US
Practice Address - Phone:505-982-5565
Practice Address - Fax:505-986-8299
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010855331041C0700X
NMC-093591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN21670034Medicare ID - Type Unspecified