Provider Demographics
NPI:1558575233
Name:CLUBB, MARK R (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:CLUBB
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11154 HURON ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2328
Mailing Address - Country:US
Mailing Address - Phone:303-920-8771
Mailing Address - Fax:
Practice Address - Street 1:11154 HURON ST
Practice Address - Street 2:SUITE 209
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-2328
Practice Address - Country:US
Practice Address - Phone:303-920-8771
Practice Address - Fax:303-920-8774
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional