Provider Demographics
NPI:1821316613
Name:NEESE, MARK (BCBA, LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:NEESE
Suffix:
Gender:M
Credentials:BCBA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11121 BLADE CREST WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-5076
Mailing Address - Country:US
Mailing Address - Phone:502-435-9226
Mailing Address - Fax:502-384-0131
Practice Address - Street 1:3432 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1018
Practice Address - Country:US
Practice Address - Phone:502-435-9226
Practice Address - Fax:502-634-1170
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-08-4859103K00000X
KY12391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst