Provider Demographics
NPI:1538781158
Name:ANTON, MARK SHELDON (MA, LAC, NCC-BC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SHELDON
Last Name:ANTON
Suffix:
Gender:M
Credentials:MA, LAC, NCC-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 ACACIA DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1222
Mailing Address - Country:US
Mailing Address - Phone:928-814-9544
Mailing Address - Fax:
Practice Address - Street 1:8300 ACACIA DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1222
Practice Address - Country:US
Practice Address - Phone:928-814-9544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17818101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health