Provider Demographics
NPI:1427247097
Name:ANDERSON, MARK N (BA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:N
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:17160 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:NUNICA
Mailing Address - State:MI
Mailing Address - Zip Code:49448-9450
Mailing Address - Country:US
Mailing Address - Phone:616-847-4460
Mailing Address - Fax:616-847-4467
Practice Address - Street 1:17160 130TH AVE
Practice Address - Street 2:
Practice Address - City:NUNICA
Practice Address - State:MI
Practice Address - Zip Code:49448-9450
Practice Address - Country:US
Practice Address - Phone:616-847-4460
Practice Address - Fax:616-847-4467
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness