Provider Demographics
NPI:1811627714
Name:STANLEY, MARK AUSTIN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AUSTIN
Last Name:STANLEY
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 1:375 SE BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6000
Mailing Address - Country:US
Mailing Address - Phone:910-725-0702
Mailing Address - Fax:
Practice Address - Street 1:375 SE BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-6000
Practice Address - Country:US
Practice Address - Phone:910-725-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician