Provider Demographics
NPI:1508984709
Name:BABCOCK, MARK EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:BABCOCK
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 1:909 3RD AVE
Mailing Address - Street 2:#4
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7013
Mailing Address - Country:US
Mailing Address - Phone:720-635-0711
Mailing Address - Fax:303-682-9197
Practice Address - Street 1:1308 VIVIAN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3217
Practice Address - Country:US
Practice Address - Phone:720-635-0711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9898901041C0700X
VA09040016601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical