Provider Demographics
NPI:1518979889
Name:PREMSELAAR, MARK A (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:PREMSELAAR
Suffix:
Gender:M
Credentials:MSW, LCSW
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Other - First Name:
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Mailing Address - Street 1:780 CORONADO CENTER DRIVE
Mailing Address - Street 2:SUITE 110-A
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5056
Mailing Address - Country:US
Mailing Address - Phone:702-358-0464
Mailing Address - Fax:702-506-0098
Practice Address - Street 1:780 CORONADO CENTER DR
Practice Address - Street 2:SUITE 110-A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5040
Practice Address - Country:US
Practice Address - Phone:702-358-0464
Practice Address - Fax:702-506-0098
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV5782-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA106434LTDMedicare PIN