Provider Demographics
NPI:1992596498
Name:HERIFORD, MARK ALLEN (LPC, CADC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:HERIFORD
Suffix:
Gender:M
Credentials:LPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2814
Mailing Address - Country:US
Mailing Address - Phone:309-557-1400
Mailing Address - Fax:
Practice Address - Street 1:121 N LAKE DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:IL
Practice Address - Zip Code:61723-8819
Practice Address - Country:US
Practice Address - Phone:913-645-3587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.021648101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor