Provider Demographics
NPI:1598907636
Name:GUTHRIE, MARK PAUL (MA, CRC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:PAUL
Last Name:GUTHRIE
Suffix:
Gender:M
Credentials:MA, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 MARAVILLA LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7250
Mailing Address - Country:US
Mailing Address - Phone:239-278-4989
Mailing Address - Fax:
Practice Address - Street 1:2158 MARAVILLA LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7250
Practice Address - Country:US
Practice Address - Phone:239-278-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6844171 79Medicaid