Provider Demographics
NPI:1538763503
Name:SPEIGHT, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SPEIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 531
Mailing Address - Street 2:
Mailing Address - City:ARROYO SECO
Mailing Address - State:NM
Mailing Address - Zip Code:87514-0531
Mailing Address - Country:US
Mailing Address - Phone:202-441-0546
Mailing Address - Fax:575-776-8553
Practice Address - Street 1:20 CIRCULO DE VISTAS
Practice Address - Street 2:
Practice Address - City:ARROYO SECO
Practice Address - State:NM
Practice Address - Zip Code:87514-0531
Practice Address - Country:US
Practice Address - Phone:202-441-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0209141101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE