Provider Demographics
NPI:1831223387
Name:DENISON, MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DENISON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36359 HARPER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2958
Mailing Address - Country:US
Mailing Address - Phone:586-792-5770
Mailing Address - Fax:586-792-5771
Practice Address - Street 1:36359 HARPER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2958
Practice Address - Country:US
Practice Address - Phone:586-792-5770
Practice Address - Fax:586-792-5771
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005775103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR67454Medicare UPIN