Provider Demographics
NPI:1801806187
Name:WALKUP, MARK STEVEN (LICSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:WALKUP
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 RIVER ST
Mailing Address - Street 2:HCRS
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2226
Mailing Address - Country:US
Mailing Address - Phone:802-886-4500
Mailing Address - Fax:802-886-4520
Practice Address - Street 1:390 RIVER ST
Practice Address - Street 2:HCRS
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2226
Practice Address - Country:US
Practice Address - Phone:207-282-1500
Practice Address - Fax:207-282-2581
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC64451041C0700X
VT089.00899391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME272600099Medicaid
MEMM6812Medicare PIN