Provider Demographics
NPI:1821487315
Name:ST. JOHN, MARK EDWIN (LCSW, CAP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWIN
Last Name:ST. JOHN
Suffix:
Gender:M
Credentials:LCSW, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 S SEACREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-8662
Mailing Address - Country:US
Mailing Address - Phone:561-336-3220
Mailing Address - Fax:
Practice Address - Street 1:3652 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-8662
Practice Address - Country:US
Practice Address - Phone:561-336-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW120461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical