MEDICARE: DR. LAVERNE DIANE MARKS PHD.

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	006574	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	006574	OTHER	CT	DEPARTMENT OF PUBLIC HEALTH

General Provider Information

NPI Number	:	1295476158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAVERNE DIANE MARKS PHD.

Provider Business Mailing Address
First Line	:	PO BOX 7187
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-0187
Country	:	US
Telephone Number	:	856-278-3349
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 COUNTY ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-3301
Country	:	US
Telephone Number	:	856-278-3349
Fax Number	:

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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