Provider Demographics
NPI:1558486894
Name:HEAD, MARK ANDREW (LCSW, CASAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:HEAD
Suffix:
Gender:M
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:ANDREW
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW,CASAC
Mailing Address - Street 1:877 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2933
Mailing Address - Country:US
Mailing Address - Phone:585-507-2871
Mailing Address - Fax:585-442-5032
Practice Address - Street 1:877 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2933
Practice Address - Country:US
Practice Address - Phone:585-507-2871
Practice Address - Fax:585-442-5032
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO282171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRO28217OtherCLINICAL SOCIAL WORKER