Provider Demographics
NPI:1720201007
Name:MARK E NOLL PHD PC
Entity Type:Organization
Organization Name:MARK E NOLL PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:NOLL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:219-465-7674
Mailing Address - Street 1:158 NAPOLEON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5529
Mailing Address - Country:US
Mailing Address - Phone:219-465-7674
Mailing Address - Fax:219-462-0329
Practice Address - Street 1:158 NAPOLEON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5529
Practice Address - Country:US
Practice Address - Phone:219-465-7674
Practice Address - Fax:219-462-0329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010455A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty