Provider Demographics
NPI:1346088747
Name:AUGUSTINE, MARK ANTHONY
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:AUGUSTINE
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 1:645 RICHELIEU PKWY
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-2756
Mailing Address - Country:US
Mailing Address - Phone:318-308-0970
Mailing Address - Fax:
Practice Address - Street 1:645 RICHELIEU PKWY
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2756
Practice Address - Country:US
Practice Address - Phone:318-308-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA800727633103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical