Provider Demographics
NPI:1760503718
Name:DELONG, MARK (CADAC II, MSED, CCS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DELONG
Suffix:
Gender:M
Credentials:CADAC II, MSED, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 W GREEN RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4326
Mailing Address - Country:US
Mailing Address - Phone:812-699-0144
Mailing Address - Fax:
Practice Address - Street 1:645 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3846
Practice Address - Country:US
Practice Address - Phone:812-336-3570
Practice Address - Fax:812-336-9010
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC1192101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)