Provider Demographics
NPI:1720024839
Name:MARK ALLEN FDT
Entity Type:Organization
Organization Name:MARK ALLEN FDT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:HARMS
Authorized Official - Suffix:
Authorized Official - Credentials:BEHAVIORAL HEALTH TE
Authorized Official - Phone:602-973-3727
Mailing Address - Street 1:2622 W STATE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051
Mailing Address - Country:US
Mailing Address - Phone:602-973-3727
Mailing Address - Fax:602-841-2864
Practice Address - Street 1:2622 W STATE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051
Practice Address - Country:US
Practice Address - Phone:602-973-3727
Practice Address - Fax:602-841-2864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ754342OtherAHCUS