Provider Demographics
NPI:1285964023
Name:WARK, ROBERT D (MA LMFT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:WARK
Suffix:
Gender:M
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 JEFFERSON BLVD
Mailing Address - Street 2:PO BOX 3
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9572
Mailing Address - Country:US
Mailing Address - Phone:763-367-6080
Mailing Address - Fax:763-263-7897
Practice Address - Street 1:101 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-9572
Practice Address - Country:US
Practice Address - Phone:763-367-6080
Practice Address - Fax:763-263-7897
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2097106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist