Provider Demographics
NPI:1659907012
Name:DISBROW, MARK JR (IADC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DISBROW
Suffix:JR
Gender:M
Credentials:IADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11016 218TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS JUNCTION
Mailing Address - State:IA
Mailing Address - Zip Code:52738-9166
Mailing Address - Country:US
Mailing Address - Phone:417-664-3454
Mailing Address - Fax:
Practice Address - Street 1:3601 16TH AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-2328
Practice Address - Country:US
Practice Address - Phone:319-390-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101YA0400X
MO7379101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7379OtherMISSOURI CREDENTIALING BOARD