Provider Demographics
NPI:1598742777
Name:PROROK, ALEXANDER MARK (LPC)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:MARK
Last Name:PROROK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 COUNTY ROAD 4990
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65793-0506
Mailing Address - Country:US
Mailing Address - Phone:417-469-2951
Mailing Address - Fax:
Practice Address - Street 1:3670 COUNTY ROAD 4990
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-0506
Practice Address - Country:US
Practice Address - Phone:417-469-2951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002032260101YM0800X, 251C00000X, 320900000X, 385H00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498342609Medicaid
MO858342603Medicaid