Provider Demographics
NPI:1922240555
Name:PERRON, MARK STEPHEN (MS,LCPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
Last Name:PERRON
Suffix:
Gender:M
Credentials:MS,LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 COVE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2514
Mailing Address - Country:US
Mailing Address - Phone:207-712-5505
Mailing Address - Fax:
Practice Address - Street 1:52 COVE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2514
Practice Address - Country:US
Practice Address - Phone:207-712-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6490101YM0800X
MECC349101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health