Provider Demographics
NPI:1801177480
Name:MORMAN, MARK SCOTT (RAS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SCOTT
Last Name:MORMAN
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6135 TERRELL DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-5522
Mailing Address - Country:US
Mailing Address - Phone:916-534-2136
Mailing Address - Fax:
Practice Address - Street 1:6135 TERRELL DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-5522
Practice Address - Country:US
Practice Address - Phone:916-534-2136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM1009101124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)