Provider Demographics
NPI:1013069137
Name:DEARING, MARK RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:DEARING
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 MOSSY CYPRESS LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-5023
Mailing Address - Country:US
Mailing Address - Phone:904-477-5678
Mailing Address - Fax:
Practice Address - Street 1:12412 SAN JOSE BLVD STE 401
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8620
Practice Address - Country:US
Practice Address - Phone:904-348-0343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2020-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00009531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3224Medicare PIN