Provider Demographics
NPI:1285107722
Name:DANE, MARK ALAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:DANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 MARQUITA AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6170
Mailing Address - Country:US
Mailing Address - Phone:714-932-7272
Mailing Address - Fax:
Practice Address - Street 1:6600 LBJ FWY STE 240
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6550
Practice Address - Country:US
Practice Address - Phone:714-932-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14677101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health