Provider Demographics
NPI:1689786147
Name:PROSSER, MARK WILMOT (MS,LPC,LMFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILMOT
Last Name:PROSSER
Suffix:
Gender:M
Credentials:MS,LPC,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 UNIVERSITY CITY BLVD
Mailing Address - Street 2:SUITE#1
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-2708
Mailing Address - Country:US
Mailing Address - Phone:540-961-2380
Mailing Address - Fax:540-961-3408
Practice Address - Street 1:820 UNIVERSITY CITY BLVD
Practice Address - Street 2:SUITE#1
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-2708
Practice Address - Country:US
Practice Address - Phone:540-961-2380
Practice Address - Fax:540-961-3408
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001291101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor