Provider Demographics
NPI:1124431671
Name:ELIZONDO, MARK (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ELIZONDO
Suffix:
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 1:9962 WAKE BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-4733
Mailing Address - Country:US
Mailing Address - Phone:817-917-2426
Mailing Address - Fax:
Practice Address - Street 1:2121 W SPRING CREEK PKWY STE 204
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-4539
Practice Address - Country:US
Practice Address - Phone:817-917-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX543121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical