Provider Demographics
NPI:1003399403
Name:GONCHAR, MARK (LASAC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GONCHAR
Suffix:
Gender:M
Credentials:LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:RIMROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86335-0230
Mailing Address - Country:US
Mailing Address - Phone:928-567-1322
Mailing Address - Fax:
Practice Address - Street 1:3095 E CORONADO TRL
Practice Address - Street 2:
Practice Address - City:RIMROCK
Practice Address - State:AZ
Practice Address - Zip Code:86335-5284
Practice Address - Country:US
Practice Address - Phone:928-567-1322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13156101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)