Provider Demographics
NPI:1629131263
Name:THEODORE, MARK FRANCIS (MA, LSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:FRANCIS
Last Name:THEODORE
Suffix:
Gender:M
Credentials:MA, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-1733
Mailing Address - Country:US
Mailing Address - Phone:508-674-5600
Mailing Address - Fax:508-235-5009
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:508-674-5600
Practice Address - Fax:508-235-5009
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3024783101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional