Provider Demographics
NPI:1780315556
Name:ACEBEROS, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ACEBEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20488 SE BYRON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-8821
Mailing Address - Country:US
Mailing Address - Phone:510-786-8556
Mailing Address - Fax:
Practice Address - Street 1:20488 SE BYRON AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-8821
Practice Address - Country:US
Practice Address - Phone:510-786-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health