Basic Information
| Provider Information | |||||||||
| NPI: | 1023550399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENT | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | 175 W BROADWAY | ||||||||
| City: | LINCOLN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044570099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077946700 | ||||||||
| FaxNumber: | 2077946777 | ||||||||
| Practice Location | |||||||||
| Address1: | 6947 E GAMEBIRD WAY | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851431243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072900948 | ||||||||
| FaxNumber: | 2077946777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2016 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | TP1500 | ME | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.