Provider Demographics
NPI:1124706510
Name:PIERCE, MARK EUGENE (LAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:PIERCE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 W ELLIOT RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1887
Mailing Address - Country:US
Mailing Address - Phone:602-750-8676
Mailing Address - Fax:
Practice Address - Street 1:813 W ELLIOT RD STE 3
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-1887
Practice Address - Country:US
Practice Address - Phone:602-750-8676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21481101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health