Provider Demographics
NPI:1457035164
Name:MARK, GRACE HANNAH (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:HANNAH
Last Name:MARK
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 FIDELITY ST APT A37
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-2065
Mailing Address - Country:US
Mailing Address - Phone:317-627-6069
Mailing Address - Fax:
Practice Address - Street 1:605 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CARRBORO
Practice Address - State:NC
Practice Address - Zip Code:27510-1693
Practice Address - Country:US
Practice Address - Phone:919-283-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0190091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical