Provider Demographics
NPI:1457589665
Name:IRELAND, MARK RUSSELL (LPC, LMAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RUSSELL
Last Name:IRELAND
Suffix:
Gender:M
Credentials:LPC, LMAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:KS
Mailing Address - Zip Code:66434-2774
Mailing Address - Country:US
Mailing Address - Phone:785-742-7113
Mailing Address - Fax:
Practice Address - Street 1:909 S 2ND ST
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2774
Practice Address - Country:US
Practice Address - Phone:785-742-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1841281805Medicaid