Provider Demographics
NPI:1922257484
Name:KISNER, MARK RONALD (MSW, CADC-II)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RONALD
Last Name:KISNER
Suffix:
Gender:M
Credentials:MSW, CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 THALIA ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2714
Mailing Address - Country:US
Mailing Address - Phone:714-913-0852
Mailing Address - Fax:949-497-3687
Practice Address - Street 1:316 THALIA ST
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2714
Practice Address - Country:US
Practice Address - Phone:714-913-0852
Practice Address - Fax:949-497-3687
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARA851306101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARA851306OtherCERTIFICATION BOARD OF ALCOHOL AND DRUG COUNSELORS