Provider Demographics
NPI:1487783692
Name:HOUSE, MARK ANDREW (MA,)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:HOUSE
Suffix:
Gender:M
Credentials:MA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:13668-3205
Mailing Address - Country:US
Mailing Address - Phone:315-353-9964
Mailing Address - Fax:
Practice Address - Street 1:5862 US HIGHWAY # 11
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-379-0805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003421101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health