Provider Demographics
NPI:1932314093
Name:SPEETZEN, MARK ALAN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:SPEETZEN
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 1:2145 E HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3811
Mailing Address - Country:US
Mailing Address - Phone:520-327-4750
Mailing Address - Fax:
Practice Address - Street 1:1010 E 10TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5813
Practice Address - Country:US
Practice Address - Phone:520-225-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10Medicaid