Provider Demographics
NPI:1356619845
Name:WALDE LOEWEN, MARK RICHARD (LPC, RPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:WALDE LOEWEN
Suffix:
Gender:M
Credentials:LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10128 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3300
Mailing Address - Country:US
Mailing Address - Phone:804-276-5761
Mailing Address - Fax:804-555-5555
Practice Address - Street 1:10128 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3300
Practice Address - Country:US
Practice Address - Phone:804-276-5761
Practice Address - Fax:804-555-5555
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004844101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health