Provider Demographics
NPI:1710174545
Name:FRILLMAN, MARK JOHN (LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:FRILLMAN
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 S 112TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4701
Mailing Address - Country:US
Mailing Address - Phone:402-812-5684
Mailing Address - Fax:
Practice Address - Street 1:445 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-5668
Practice Address - Country:US
Practice Address - Phone:402-721-7169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE203101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)