Healthcare Provider Details

I. General information

NPI: 1598742777
Provider Name (Legal Business Name): ALEXANDER MARK PROROK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 COUNTY ROAD 4990
WILLOW SPRINGS MO
65793-0506
US

IV. Provider business mailing address

3670 COUNTY ROAD 4990
WILLOW SPRINGS MO
65793-0506
US

V. Phone/Fax

Practice location:
  • Phone: 417-469-2951
  • Fax:
Mailing address:
  • Phone: 417-469-2951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2002032260
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number2002032260
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2002032260
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number2002032260
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number2002032260
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: