Provider Demographics
NPI:1598339426
Name:BLOCKUS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BLOCKUS
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:PO BOX 27554
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-2554
Mailing Address - Country:US
Mailing Address - Phone:512-481-2722
Mailing Address - Fax:
Practice Address - Street 1:4413 SPICEWOOD SPRINGS RD # 105
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8580
Practice Address - Country:US
Practice Address - Phone:512-481-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-15
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health