Provider Demographics
NPI:1609085992
Name:VANHOOSE, MARK ALLEN (LISW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:VANHOOSE
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 OAKHILL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5667
Mailing Address - Country:US
Mailing Address - Phone:937-879-1830
Mailing Address - Fax:
Practice Address - Street 1:4431 MARKETING PL
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9556
Practice Address - Country:US
Practice Address - Phone:614-836-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.00275521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical