Provider Demographics
NPI:1942544630
Name:WARDLOW, MARK ERNEST JR (MA, LPC, CCDP-D)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ERNEST
Last Name:WARDLOW
Suffix:JR
Gender:M
Credentials:MA, LPC, CCDP-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 HIGHWAY H
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7042
Mailing Address - Country:US
Mailing Address - Phone:573-915-4123
Mailing Address - Fax:
Practice Address - Street 1:1528 HIGHWAY H
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-7042
Practice Address - Country:US
Practice Address - Phone:573-915-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5866101YA0400X
MO2016014454101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)