Provider Demographics
NPI:1568125458
Name:BEACH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BEACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S STEPHANIE ST APT 1611
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-4412
Mailing Address - Country:US
Mailing Address - Phone:562-714-2276
Mailing Address - Fax:
Practice Address - Street 1:6671 LAS VEGAS BLVD S UNIT 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3289
Practice Address - Country:US
Practice Address - Phone:833-223-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT1126106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty