Provider Demographics
NPI:1184083206
Name:TACK, MARK (LMSW, ADC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:TACK
Suffix:
Gender:M
Credentials:LMSW, ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7424 APENNINES DR
Mailing Address - Street 2:ARMY SUBSTANCE ABUSE PROGRAM (ASAP)
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7151
Mailing Address - Country:US
Mailing Address - Phone:785-239-0662
Mailing Address - Fax:
Practice Address - Street 1:7424 APENNINES DR
Practice Address - Street 2:ARMY SUBSTANCE ABUSE PROGRAM (ASAP)
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-7151
Practice Address - Country:US
Practice Address - Phone:785-239-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9430104100000X
FLISW 8702104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS9430OtherLICENSED MASTER SOCIAL WORKER
FLISW 8702OtherREGISTERED CLINICAL SOCIAL WORKER INTERN