Healthcare Provider Details

I. General information

NPI: 1164727103
Provider Name (Legal Business Name): MARK CALVERT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W. KILGORE AVE.
MUNCIE IN
47304-4810
US

IV. Provider business mailing address

3700 WEST KILGORE AVE.
MUNCIE IN
47304-4810
US

V. Phone/Fax

Practice location:
  • Phone: 765-289-5437
  • Fax: 765-213-5094
Mailing address:
  • Phone: 765-289-5437
  • Fax: 765-213-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: