Provider Demographics
NPI:1558438838
Name:GARNER, MARK MCKELVY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MCKELVY
Last Name:GARNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12935 S WEST BAY SHORE DR STE 260
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5597
Mailing Address - Country:US
Mailing Address - Phone:231-642-1641
Mailing Address - Fax:
Practice Address - Street 1:12935 S WEST BAY SHORE DR STE 260
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5597
Practice Address - Country:US
Practice Address - Phone:231-642-1641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-B8-4791OtherBLUE CROSS BLUE SHIELD
MIM025581OtherCHAMPUSTRICARE
MI68-0-B8-4791OtherMICHIGAN BLUE CROSS BLUE SHIELD
MI0M19480Medicare ID - Type Unspecified