Provider Demographics
NPI:1952387037
Name:ANDERSON, MARK WILLIAM (LPC LICDC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPC LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6873
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-0873
Mailing Address - Country:US
Mailing Address - Phone:419-729-0630
Mailing Address - Fax:419-729-0570
Practice Address - Street 1:3454 OAK ALLEY CT
Practice Address - Street 2:#410
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1306
Practice Address - Country:US
Practice Address - Phone:419-729-0630
Practice Address - Fax:419-729-0570
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH78211101YA0400X
OHC0002527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)