Provider Demographics
NPI:1417772708
Name:KROLL, MARK J
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:KROLL
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 1:1284 N DOWNING ST UNIT 501
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-2180
Mailing Address - Country:US
Mailing Address - Phone:303-859-1447
Mailing Address - Fax:
Practice Address - Street 1:6909 S HOLLY CIR STE 304
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1045
Practice Address - Country:US
Practice Address - Phone:720-828-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0021454101YP2500X
CO24407356101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional