Provider Demographics
NPI:1871953182
Name:MARK BALDWIN
Entity type:Organization
Organization Name:MARK BALDWIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP
Authorized Official - Phone:731-467-0504
Mailing Address - Street 1:575 S ROYAL ST
Mailing Address - Street 2:SUITE 24
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7307
Mailing Address - Country:US
Mailing Address - Phone:731-467-0504
Mailing Address - Fax:
Practice Address - Street 1:575 S ROYAL ST
Practice Address - Street 2:SUITE 24
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7307
Practice Address - Country:US
Practice Address - Phone:731-467-0504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty