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NPI Code Detail

MEDICARE: MARK VENTRELLA LMFT, QMHP

MEDICARE: MARK VENTRELLA LMFT, QMHP
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
1106H00000XMarriage & Family TherapistLMFT1159SD

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14997408OTHERSDBLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number : 1952435109
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK VENTRELLA LMFT, QMHP
Provider Business Mailing Address
First Line : 840 STATE ST
Second Line :
City : SPEARFISH
State : SD
Zip : 57783-2140
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 350 ELK ST
Second Line :
City : RAPID CITY
State : SD
Zip : 57701-7351
Country : US
Telephone Number : 605-343-7262
Fax Number : 605-343-7293
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/16/2007
Last Update Date : 11/07/2007

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