Provider Demographics
NPI:1639369028
Name:BARNSTABLE, MARK EUGENE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:BARNSTABLE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2371 NE STEPHENS ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1372
Mailing Address - Country:US
Mailing Address - Phone:541-672-8533
Mailing Address - Fax:541-672-4993
Practice Address - Street 1:2371 NE STEPHENS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1372
Practice Address - Country:US
Practice Address - Phone:541-672-8533
Practice Address - Fax:541-672-4993
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL55381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165772Medicaid
R167160Medicare PIN