Healthcare Provider Details

I. General information

NPI: 1164712139
Provider Name (Legal Business Name): MR. MARK JOHN PLOURD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WOODLAND ST
HARTFORD CT
06105-1233
US

IV. Provider business mailing address

701 GOVERNORS HWY
SOUTH WINDSOR CT
06074-2508
US

V. Phone/Fax

Practice location:
  • Phone: 860-520-6202
  • Fax:
Mailing address:
  • Phone: 860-878-5477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: