Provider Demographics
NPI:1912657008
Name:SLAUGHTER, MARK ANTHONY JR (MFTA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:SLAUGHTER
Suffix:JR
Gender:M
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 BARTLETT CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2772
Mailing Address - Country:US
Mailing Address - Phone:502-439-7773
Mailing Address - Fax:
Practice Address - Street 1:12730 TOWNEPARK WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2303
Practice Address - Country:US
Practice Address - Phone:502-254-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
KY275560106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist