Provider Demographics
NPI:1922554161
Name:MCPHERSON, MARK DAVID (MED)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:MCPHERSON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2136 WEST M-32
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735
Mailing Address - Country:US
Mailing Address - Phone:989-732-1791
Mailing Address - Fax:989-732-7052
Practice Address - Street 1:2136 WEST M-32
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735
Practice Address - Country:US
Practice Address - Phone:989-732-1791
Practice Address - Fax:989-732-7052
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01298101YA0400X
MIS-20162101YA0400X
MID-10011101YA0400X
MI6802058697104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)