Provider Demographics
NPI:1629272497
Name:LOVELACE, JOHN MARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARK
Last Name:LOVELACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3225 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9380
Mailing Address - Country:US
Mailing Address - Phone:719-275-2351
Mailing Address - Fax:719-269-9386
Practice Address - Street 1:3225 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9380
Practice Address - Country:US
Practice Address - Phone:719-275-2351
Practice Address - Fax:719-269-9386
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9910021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66506Medicare ID - Type UnspecifiedPROVIDER NUMBER