Provider Demographics
NPI:1831249523
Name:BRAGG, MARK W (LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:BRAGG
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4209 JOHN SILVER RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-2131
Mailing Address - Country:US
Mailing Address - Phone:757-363-2825
Mailing Address - Fax:757-363-2825
Practice Address - Street 1:4209 JOHN SILVER RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-2131
Practice Address - Country:US
Practice Address - Phone:757-363-2825
Practice Address - Fax:757-363-2825
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701003261OtherLICENSE NUMBER