Provider Demographics
NPI:1598706723
Name:LAWLESS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LAWLESS
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 1:375 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1236
Mailing Address - Country:US
Mailing Address - Phone:203-503-3075
Mailing Address - Fax:203-503-3254
Practice Address - Street 1:400 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3250
Practice Address - Fax:203-503-3254
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0050291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical