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General NPI Number Information
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NPI Number | 1124455811
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Entity Type | Individual
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Provider Name | MARK SENIOR NCC, ACADC
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Gender | Male
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Dates
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Enumeration Date | 09/26/2013
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Last Update Date | 10/28/2025
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Provider Practice Location Address
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Address Line | 1407 W MCMILLAN RD STE 120
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City | MERIDIAN
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State | ID
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Zip | 83646-5168
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Country | US
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Telephone | 208-870-4627
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Fax |
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Provider Business Mailing Address
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Address Line | 2020 S LUXURY LN APT J306
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City | MERIDIAN
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State | ID
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Zip | 83642-4423
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Country | US
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Telephone | 208-870-4627
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 8321757
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 11606
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License Number State | ID
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