Provider Demographics
NPI:1851717904
Name:PRATT, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PRATT
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 1:1003 OSPREY CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-2669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4874 LONG BEACH RD SE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-8713
Practice Address - Country:US
Practice Address - Phone:607-760-7753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9071A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist