Provider Demographics
NPI:1700443207
Name:STURGIS, MARK JR (LCAS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STURGIS
Suffix:JR
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13032 GRAYMIST DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-6030
Mailing Address - Country:US
Mailing Address - Phone:704-791-0611
Mailing Address - Fax:
Practice Address - Street 1:1933 JAKE ALEXANDER BLVD W
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1126
Practice Address - Country:US
Practice Address - Phone:704-762-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18695101YM0800X
NC24845101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1154545663Medicaid