Provider Demographics
NPI:1912419060
Name:RALLS, MARK EARL
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EARL
Last Name:RALLS
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 1:2900 BUTTERWICK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-1021
Mailing Address - Country:US
Mailing Address - Phone:513-981-1271
Mailing Address - Fax:513-381-0902
Practice Address - Street 1:834 EZZARD CHARLES DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-2525
Practice Address - Country:US
Practice Address - Phone:513-381-6672
Practice Address - Fax:513-381-0902
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH991615101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)