Provider Demographics
NPI:1063977247
Name:HALE, MARK THOMAS JR (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:HALE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 SPENCER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2576
Mailing Address - Country:US
Mailing Address - Phone:636-939-2550
Mailing Address - Fax:636-939-2551
Practice Address - Street 1:255 SPENCER RD STE 101
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2574
Practice Address - Country:US
Practice Address - Phone:636-939-2550
Practice Address - Fax:636-939-2551
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240176251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201844613OtherLICENSE
MO2024017625OtherLICENSE