Provider Demographics
NPI:1790319069
Name:SPECK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SPECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-2900
Mailing Address - Country:US
Mailing Address - Phone:606-278-6096
Mailing Address - Fax:
Practice Address - Street 1:1215 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2900
Practice Address - Country:US
Practice Address - Phone:606-278-6096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171888101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health