Provider Demographics
NPI:1558940866
Name:CHARPENTIER, MARK (OWNER)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CHARPENTIER
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CHESTERFIELD COMMONS RD E
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1440
Mailing Address - Country:US
Mailing Address - Phone:636-532-0705
Mailing Address - Fax:636-532-0012
Practice Address - Street 1:112 CHESTERFIELD COMMONS RD E
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1440
Practice Address - Country:US
Practice Address - Phone:636-532-0705
Practice Address - Fax:636-532-0012
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106S00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician