Provider Demographics
NPI:1770502379
Name:WORTHEN, MARK DAVID (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:WORTHEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:D
Other - Last Name:WORTHEN PSYD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 410105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28241-0105
Mailing Address - Country:US
Mailing Address - Phone:980-391-6309
Mailing Address - Fax:980-729-5870
Practice Address - Street 1:12907 YORKRIDGE DR APT 417
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273
Practice Address - Country:US
Practice Address - Phone:208-244-4052
Practice Address - Fax:980-729-5870
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1835103TA0400X, 103TC0700X
UT10951856-2501103TF0200X, 103TP2701X
103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000718Medicaid