Basic Information
| Provider Information | |||||||||
| NPI: | 1205080660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRITTON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1363 FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1363 FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2008 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-4077 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | LCPC-4894 | ID | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.