Healthcare Provider Details

I. General information

NPI: 1942829783
Provider Name (Legal Business Name): DINA MARK M.ED, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2020
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 LAKE PLAZA DR
COLORADO SPRINGS CO
80906-3553
US

IV. Provider business mailing address

3360 SPRINGRIDGE CIR
COLORADO SPRINGS CO
80906-3734
US

V. Phone/Fax

Practice location:
  • Phone: 719-362-5440
  • Fax:
Mailing address:
  • Phone: 719-339-8294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number289529
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0017543
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: