Provider Demographics
NPI:1952879520
Name:MANSFIELD, MARK D (MC, LAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MANSFIELD
Suffix:
Gender:M
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5139 E TANO ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-4120
Mailing Address - Country:US
Mailing Address - Phone:480-241-8119
Mailing Address - Fax:
Practice Address - Street 1:15820 N 35TH AVE STE 14
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-7608
Practice Address - Country:US
Practice Address - Phone:602-859-9169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20544101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-20544OtherAZ BOARD OF BEHAVIORAL HEALTH