MEDICARE: MR. MARK BRIGGS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	PRO12505-1	NY

General Provider Information

NPI Number	:	1164587879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK BRIGGS LCSW

Provider Business Mailing Address
First Line	:	412 MAPLE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1734
Country	:	US
Telephone Number	:	315-446-4914
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 MAPLE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1734
Country	:	US
Telephone Number	:	315-432-1514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	10/20/2014

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