Provider Demographics
NPI:1902503667
Name:MARKS, ERIC D SR (DTH, MTH, CTC, CPC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:D
Last Name:MARKS
Suffix:SR
Gender:M
Credentials:DTH, MTH, CTC, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 RIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2232
Mailing Address - Country:US
Mailing Address - Phone:706-489-6163
Mailing Address - Fax:
Practice Address - Street 1:406 RIDLEY AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2232
Practice Address - Country:US
Practice Address - Phone:706-489-6163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22468101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral