MEDICARE: MR. ALEXANDER MARK PROROK LPC

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	2002032260	MO
2	251C00000X	Developmentally Disabled Services Day Training Agency	2002032260	MO
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	2002032260	MO
4	385H00000X	Respite Care	2002032260	MO
5	3747P1801X	Personal Care Attendant	2002032260	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598742777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEXANDER MARK PROROK LPC

Provider Business Mailing Address
First Line	:	3670 COUNTY ROAD 4990
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-0506
Country	:	US
Telephone Number	:	417-469-2951
Fax Number	:

Provider Business Practice Location Address
First Line	:	3670 COUNTY ROAD 4990
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-0506
Country	:	US
Telephone Number	:	417-469-2951
Fax Number	:

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

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	08/26/2008

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Directions to “ MR. ALEXANDER MARK PROROK LPC” Practice Location

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