Provider Demographics
NPI:1679533673
Name:LESSARD, MARK D (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:LESSARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EBH02
Mailing Address - Street 2:4TH ARMORED DRIVE
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-6703
Mailing Address - Fax:
Practice Address - Street 1:EBH02
Practice Address - Street 2:4TH ARMORED DRIVE
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2104-057103TC0700X
TX3-1940103TC0700X
VT725103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical