Provider Demographics
NPI:1124455811
Name:SENIOR, MARK (NCC, ACADC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SENIOR
Suffix:
Gender:M
Credentials:NCC, ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N BENJAMIN LN STE 201
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5094
Mailing Address - Country:US
Mailing Address - Phone:208-287-5612
Mailing Address - Fax:208-287-5609
Practice Address - Street 1:400 N BENJAMIN LN STE 201
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5094
Practice Address - Country:US
Practice Address - Phone:208-287-5612
Practice Address - Fax:208-287-5609
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63836101Y00000X
ID10158101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)