Provider Demographics
NPI:1508884370
Name:KRIST, MARK J (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:KRIST
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 RUTTER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4136
Mailing Address - Country:US
Mailing Address - Phone:646-691-7790
Mailing Address - Fax:
Practice Address - Street 1:USAMEDDAC
Practice Address - Street 2:2480 LLEWELLYN AVE
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755
Practice Address - Country:US
Practice Address - Phone:301-677-8136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010855331041C0700X
NMC-093591041C0700X
MD312101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN21670034Medicare ID - Type Unspecified