Provider Demographics
NPI:1912440181
Name:FRALICK, MARK DAVID (LADC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:FRALICK
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 INTERVALE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-1761
Mailing Address - Country:US
Mailing Address - Phone:508-309-2254
Mailing Address - Fax:617-328-0409
Practice Address - Street 1:675 E 4TH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-3063
Practice Address - Country:US
Practice Address - Phone:857-496-7336
Practice Address - Fax:857-496-0177
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13521101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)