Provider Demographics
NPI:1720306228
Name:GERISCH, MARK A (MA, LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GERISCH
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9615
Mailing Address - Country:US
Mailing Address - Phone:989-269-9293
Mailing Address - Fax:989-269-7544
Practice Address - Street 1:1108 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9615
Practice Address - Country:US
Practice Address - Phone:989-269-9293
Practice Address - Fax:989-269-7544
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008649101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional