Provider Demographics
NPI:1568687051
Name:DESKOVITZ, MARK ALLAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:DESKOVITZ
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 1:104 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2791
Mailing Address - Country:US
Mailing Address - Phone:989-486-3021
Mailing Address - Fax:989-486-1843
Practice Address - Street 1:104 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2791
Practice Address - Country:US
Practice Address - Phone:989-486-3021
Practice Address - Fax:989-486-1843
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013322103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION15630Medicare ID - Type UnspecifiedPARTNERS IN CHANGE