Provider Demographics
NPI:1841520178
Name:SEYMOUR, MARK W (PCC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4737
Mailing Address - Country:US
Mailing Address - Phone:419-557-5177
Mailing Address - Fax:419-557-5179
Practice Address - Street 1:710 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3224
Practice Address - Country:US
Practice Address - Phone:419-334-6619
Practice Address - Fax:419-334-6663
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0005669101YM0800X
OHE 0005669101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0156327Medicaid