Provider Demographics
NPI:1063541407
Name:HARTIGAN, MARK PATRICK (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:PATRICK
Last Name:HARTIGAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 ARBORWOODS DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5282
Mailing Address - Country:US
Mailing Address - Phone:678-549-0268
Mailing Address - Fax:770-640-6853
Practice Address - Street 1:3949 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2207
Practice Address - Country:US
Practice Address - Phone:678-549-0268
Practice Address - Fax:770-640-6853
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00490168AMedicaid
GAS25289Medicare UPIN
GA68BBCTVMedicare ID - Type Unspecified