Provider Demographics
NPI:1750822805
Name:STALLS, MARK (CPED)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STALLS
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 SANTA MONICA DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-8522
Mailing Address - Country:US
Mailing Address - Phone:940-367-0641
Mailing Address - Fax:940-383-4144
Practice Address - Street 1:3106 SANTA MONICA DR
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-8522
Practice Address - Country:US
Practice Address - Phone:940-367-0641
Practice Address - Fax:940-383-4144
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXABC CPED 1094405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional