Provider Demographics
NPI:1285808204
Name:REAVES, MARK (LCSW-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:REAVES
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 LIBERTY RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6420
Mailing Address - Country:US
Mailing Address - Phone:410-552-0773
Mailing Address - Fax:410-552-0774
Practice Address - Street 1:1425 LIBERTY RD
Practice Address - Street 2:SUITE 208
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6420
Practice Address - Country:US
Practice Address - Phone:410-552-0773
Practice Address - Fax:410-552-0774
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD126281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical