Provider Demographics
NPI:1942829783
Name:MARK, DINA (MED, NCC)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:MED, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3360 SPRINGRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3734
Mailing Address - Country:US
Mailing Address - Phone:719-339-8294
Mailing Address - Fax:
Practice Address - Street 1:1287 LAKE PLAZA DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3553
Practice Address - Country:US
Practice Address - Phone:719-362-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-12
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO289529101YS0200X
COLPC.0017543101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool