Provider Demographics
NPI:1548353360
Name:SOLOMON, JOHN MARK (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARK
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-1012
Mailing Address - Country:US
Mailing Address - Phone:903-670-1420
Mailing Address - Fax:903-670-2599
Practice Address - Street 1:506 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3430
Practice Address - Country:US
Practice Address - Phone:903-677-4800
Practice Address - Fax:903-677-4803
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX275651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100823701Medicaid
0046OEMedicare PIN