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General NPI Number Information
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NPI Number | 1518952662
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Entity Type | Individual
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Provider Name | MARK STEWART SIMPSON PSYD, LADAC
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Gender | Male
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Dates
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Enumeration Date | 09/14/2005
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Last Update Date | 01/31/2014
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Provider Practice Location Address
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Address Line | CORNER OF ROUTE N12 AND N7 FORT DEFIANCE INDIAN HOSPITAL BOARD, INC
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City | FORT DEFIANCE
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State | AZ
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Zip | 86504-0649
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Country | US
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Telephone | 928-729-8506
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Fax | 928-729-8502
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Provider Business Mailing Address
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Address Line | PO BOX 649 FORT DEFIANCE INDIAN HOSPITAL BOARD, INC
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City | FORT DEFIANCE
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State | AZ
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Zip | 86504-0649
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Country | US
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Telephone | 928-729-8506
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Fax | 928-729-8502
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0081081
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0930
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License Number State | NM
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