Provider Demographics
NPI:1518622877
Name:HORAN, MARK DAVID (MSE, LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:HORAN
Suffix:
Gender:M
Credentials:MSE, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 E 5TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3794
Mailing Address - Country:US
Mailing Address - Phone:715-817-5325
Mailing Address - Fax:
Practice Address - Street 1:4615 GRAND AVE STE 330
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2749
Practice Address - Country:US
Practice Address - Phone:218-207-2132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301987101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)