Provider Demographics
NPI:1952123556
Name:PLUMMER, MARK ANTHONY
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:PLUMMER
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 1:4859 NW 55TH DR
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-3313
Mailing Address - Country:US
Mailing Address - Phone:954-612-2119
Mailing Address - Fax:
Practice Address - Street 1:7461 NW 36TH ST
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-4903
Practice Address - Country:US
Practice Address - Phone:954-380-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-26
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-386358106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician