Provider Demographics
NPI:1861555336
Name:PESNER, MARK J (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:PESNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 US HIGHWAY 46
Mailing Address - Street 2:SUITE G101
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-2440
Mailing Address - Country:US
Mailing Address - Phone:973-276-9040
Mailing Address - Fax:973-276-9062
Practice Address - Street 1:271 US HIGHWAY 46
Practice Address - Street 2:SUITE G101
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2440
Practice Address - Country:US
Practice Address - Phone:973-276-9040
Practice Address - Fax:973-276-9062
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2562103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPE 613321Medicare ID - Type Unspecified