Basic Information
| Provider Information | |||||||||
| NPI: | 1346371135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS, CSACII, CCGC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3012 KENTUCKY AVE | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042745 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 305 S VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648012323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 05/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 2805 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251B00000X | 2805 | MO | N | Agencies | Case Management |
No ID Information.