Provider Demographics
NPI:1831490564
Name:BABULA, MARK ALAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:BABULA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5965 RENAISSANCE PL STE 1
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4728
Mailing Address - Country:US
Mailing Address - Phone:419-882-5678
Mailing Address - Fax:419-882-7446
Practice Address - Street 1:5965 RENAISSANCE PL STE 1
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4728
Practice Address - Country:US
Practice Address - Phone:419-882-5678
Practice Address - Fax:419-882-7446
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6565103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical