Provider Demographics
NPI:1720276108
Name:PERKINS, MARK GREGORY (LADC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GREGORY
Last Name:PERKINS
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 1ST AVE NE
Mailing Address - Street 2:SUITE 111-D
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-4170
Mailing Address - Country:US
Mailing Address - Phone:507-529-1758
Mailing Address - Fax:507-289-1536
Practice Address - Street 1:1500 1ST AVE NE
Practice Address - Street 2:SUITE 111-D
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-4170
Practice Address - Country:US
Practice Address - Phone:507-529-1758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300101101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)