Provider Demographics
NPI:1184343063
Name:MCGOWAN, MARK JOSEPH SR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:MCGOWAN
Suffix:SR
Gender:M
Credentials:
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 3051
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92202-3051
Mailing Address - Country:US
Mailing Address - Phone:760-699-3968
Mailing Address - Fax:
Practice Address - Street 1:83912 AVENUE 45 STE 9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-347-0754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI34461221101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACI34461221OtherLICENCE