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General NPI Number Information
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NPI Number | 1548561046
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Entity Type | Individual
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Provider Name | TANYA M MARK LPC
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Gender | Female
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Dates
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Enumeration Date | 11/15/2010
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Last Update Date | 12/30/2014
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Provider Practice Location Address
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Address Line | 9666 OLIVE BLVD SUITE 400
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City | SAINT LOUIS
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State | MO
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Zip | 63132-3013
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Country | US
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Telephone | 314-785-7274
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Fax |
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Provider Business Mailing Address
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Address Line | 6732 CREST AVE 1ST FLOOR
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City | SAINT LOUIS
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State | MO
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Zip | 63130-2506
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Country | US
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Telephone | 314-704-3623
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2010037457
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License Number State | MO
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