Provider Demographics
NPI:1205080660
Name:GRITTON, MARK ALLEN (LCPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:GRITTON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3392
Mailing Address - Country:US
Mailing Address - Phone:208-736-7090
Mailing Address - Fax:208-736-7089
Practice Address - Street 1:1363 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3392
Practice Address - Country:US
Practice Address - Phone:208-736-7090
Practice Address - Fax:208-736-7089
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4077101YP2500X
IDLCPC-4894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health