Basic Information
Provider Information | |||||||||
NPI: | 1306272042 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARK | ||||||||
FirstName: | ERIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PLEIN | ||||||||
OtherFirstName: | ERIN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2257 | ||||||||
Address2: |   | ||||||||
City: | CHESTERTON | ||||||||
State: | IN | ||||||||
PostalCode: | 463040357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2199268320 | ||||||||
FaxNumber: | 2199263524 | ||||||||
Practice Location | |||||||||
Address1: | 2010 HOGBACK RD STE 6G | ||||||||
Address2: |   | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481058800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7348903519 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2013 | ||||||||
LastUpdateDate: | 06/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 6301015371 | MI | N |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   | 103TC0700X | 6301015371 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.