Healthcare Provider Details

I. General information

NPI: 1730469008
Provider Name (Legal Business Name): MARK HALVORSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W ELLIOTT ST
SAINT IGNACE MI
49781-1868
US

IV. Provider business mailing address

125 N LAKE ST
MANISTIQUE MI
49854-1234
US

V. Phone/Fax

Practice location:
  • Phone: 906-643-8616
  • Fax: 906-643-7194
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801058066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: