Provider Demographics
NPI:1215144738
Name:HIBBITT, MARK JOHNSON (MA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHNSON
Last Name:HIBBITT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5169 LAKE POINT DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033
Mailing Address - Country:US
Mailing Address - Phone:317-442-3956
Mailing Address - Fax:
Practice Address - Street 1:16162 CAREY RD
Practice Address - Street 2:RADIANT CHRISTIAN LIFE CHURCH
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074
Practice Address - Country:US
Practice Address - Phone:317-442-3956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist