Provider Demographics
NPI:1922479286
Name:MARK, JULIE (LSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 CROSSBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2258
Mailing Address - Country:US
Mailing Address - Phone:440-352-9607
Mailing Address - Fax:440-354-2296
Practice Address - Street 1:42 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-4003
Practice Address - Country:US
Practice Address - Phone:440-354-9607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0009131104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker